Timothy W. Harman, Thomas J. Graham, and Richard L. Uhl
DEFINITION
Extra-articular fractures of the phalanges include metaphyseal and diaphyseal fractures of the proximal, middle, and distal phalanges.
Extra-articular fractures of the phalanx can range from an isolated injury, which is relatively simple to treat, to a complex trauma involving multiple structures; these latter injuries are often profoundly difficult to reconstruct and can severely affect the function of the hand.
ANATOMY
The phalanges are the long, tubular bones of the hand that enable a functional arc of motion.
While each phalanx of each ray is similar, there are anatomic differences that account for the normal cascade and curvature of the digits, allowing for flexion and extension.
The extensor mechanism of the finger glides directly on top of the phalanges, with only a thin layer of periosteum and peritenon between bone and tendon (FIG 1).
Fractures of the phalanges and the resultant bleeding, swelling, and scarring can greatly inhibit extensor function.
Early motion of the extensor mechanism can help minimize adhesions between bone and tendon. This is an essential principle that must be kept in mind when treating these injuries.
Hardware, particularly a plate, placed dorsally beneath the tendon may interfere with extensor tendon function and risk its integrity. This has led many to recommend alternate fixation methods as well as plate placement on the lateral aspect of the bone.
A dorsal implant may abrade the tendon, especially if the end of the plate is at the level of the proximal interphalangeal joint.
Even a low-profile dorsal plate can lead to extensor imbalance. A plate on the proximal phalanx effectively shortens and tightens the central slip tendon, leading to limited proximal interphalangeal flexion.
There is even less room to place a dorsal plate under the triangular ligament and terminal tendon over the middle phalanx (FIG 2).
PATHOGENESIS
Because the fingers project from the hand, they are subject to bending and twisting forces in a wide variety of situations.
The fracture pattern depends on the position of the digit at the time of injury and the direction and degree of force applied.
As a rule, long spiral fractures tend to result from torsional forces and transverse fractures tend to occur after angular and three-point bending forces.
Fingers are also subject to direct trauma, such as a blow from a hammer, crush injury from a window or door, or even a gunshot.
These injuries are often associated with skin, tendon, nerve, and artery injuries, all of which worsen the prognosis for recovery of function.
Most distal phalanx fractures are comminuted in nature and result from a crush mechanism. Significant displacement of the fragments is associated with a nail bed disruption.
FIG 1 • A. Anatomic dissection of a digit showing the relationship and position of the lateral bands and extensor digitorum communis (EDC). B. Anatomic dissection showing the EDC with the important insertion of the central slip, which should not be detached if possible during the surgical approach.
FIG 2 • The terminal tendon (TT) is formed by a confluence of the lateral bands (LB). The triangular ligament (TL) keeps the tendons on the dorsal aspect of the finger. The terminal tendon is intimately associated with the middle phalanx.
Fractures of the proximal phalanx will generally assume a position of apex volar angulation.
The intrinsic muscle tendons, inserting on the proximal phalanx base, pull the proximal fragment into flexion and the central slip pulls the distal fragment into extension (FIG 3).
Fractures of the middle phalanx deform less predictably but often assume an apex volar angulation due to the pull of the flexor digitorum sublimis tendon on the volar base of the middle phalanx proximal fragment and the force exerted by the terminal extensor tendon on the distal fragment.
Both the extensor and flexor tendons insert on the distal phalanx at the base only. The flexor tendon insertion is more distal than the extensor tendon insertion. It is possible to have an extra-articular fracture between the two insertion sites, a so-called Seymour fracture, which angulates in a dorsal apex direction.
NATURAL HISTORY
Extra-articular fractures of the phalanges usually heal without treatment, but often with deformity.
It has been shown that there is a linear relationship between the degree of proximal phalanx angulation and the extensor lag.13
The correction of such deformity must be balanced with the potential for stiffness after surgical intervention as well as other potential surgical complications.
PATIENT HISTORY AND PHYSICAL FINDINGS:
Knowledge of the mechanism of injury, time from injury to treatment, previous treatments rendered, and the injury's impact on the patient's career and hobby skill set is critical.
It must be determined whether the patient has previously injured the digit and what, if any, preinjury functional limitations existed.
The clinician should evaluate the cascade of the digits, looking for subtle changes in the attitude and position of the fingers. This may help to localize areas of injury.
Pain with palpation helps localize the area of injury if there is no clear deformity of the digit and assesses fracture healing.
Phalangeal fractures can be displaced in an AP or lateral plane, rotated, or shortened or can exhibit a combination of these deformities.
Resultant hand function will depend on the specific deformity and its location along the skeleton.
The more proximal the fracture, the greater the potential deformity at the fingertip.
Rotational deformity affects ultimate function the greatest, especially if it causes the fingers to scissor (FIG 4A).
Rotation can be evaluated by asking the patient to flex and extend the digits as a unit. The clinician should compare the relative position of the injured digit to adjacent digits on the injured and uninjured hand.
A digital anesthetic block can facilitate the examination.
The digits should generally point toward the distal pole of the scaphoid during flexion.
FIG 3 • Most proximal phalanx fractures assume an apex volar angulation (red arrow). This is due to a combination of tendon forces. The intrinsic tendon (IT) insertion at the base of the proximal phalanx pulls the proximal fragment into flexion (blue arrow). The central slip (CS) is formed from the extensor tendon (ET) and contribution from the intrinsic tendon (IT) as they cross dorsally (green arrow). The central slip pulls the distal fragment into extension (yellow arrow), resulting in an apex volar angulation (red arrow). SB, sagittal bond.
FIG 4 • A. Rotational deformity is the least tolerated deformity in the fingers. Assessment can be difficult, however, if the patient cannot make a fist. B. Rotation can be assessed by observing the planes of the fingernails to each other. The nail that is rotated out of the plane of the others (in this case the ring finger) indicates a rotational deformity of that digit.
It is often difficult for the patient to make a fist at the initial assessment due to pain and swelling. In these cases, comparing the plane of the nail bed of the injured finger to the adjacent nail beds and comparing with the other hand can provide a valuable clue to the presence of a rotational deformity (FIG 4B).
Neurocirculatory status
Altered skin color and diminished turgor and capillary refill of the digit are clear indicators of vascular compromise.
Two-point discrimination can be used to assess innervation density and is an excellent method for evaluating the integrity of digital nerves.
Condition of the soft tissue envelope
The skin may be visibly damaged with lacerations, degloving, or burns. Its condition will influence treatment.
A subungual hematoma is common with a distal phalanx fracture.
Unstable fracture patterns must be recognized (Table 1).
IMAGING AND OTHER DIAGNOSTIC STUDIES:
AP, oblique, and lateral radiographs will provide sufficient imaging for the majority of extra-articular phalangeal fractures.
Critical evaluation may show subtle rotational malalignment if a true lateral view of either the base or the condyles of a phalanx does not match up across its corresponding joint.
Slightly obliqued lateral views are useful for imaging fractures at the base of the proximal phalanx, where the overlap on a true lateral view makes evaluation difficult.
A mobile, small fluoroscopy unit allows magnification to help characterize subtle injuries and dynamic evaluation to gauge fragment stability.
More sophisticated imaging (MRI, CT, ultrasound) is rarely needed to make the diagnosis of a phalangeal fracture or to guide treatment.
DIFFERENTIAL DIAGNOSIS
While there are other causes of hand pain and deformity (eg, osteoarthritis, congenital deformity, tumor, infection), the patient history and plain radiographs should leave little doubt that the patient has a phalanx fracture.
If a fracture is not evident, all the following diagnoses should be considered:
Acute sprains
Metacarpophalangeal (MP) and interphalangeal dislocations
Mallet finger
Phalangeal contusions
Benign and malignant lesions of the digits
Soft tissue injuries
Collateral ligament injury
Boutonnière or swan-neck injuries
Sagittal band ruptures
Tendon ruptures
Pulley ruptures
Stenosing tenosynovitis or trigger finger
Acute infection
NONOPERATIVE MANAGEMENT
Many phalangeal fractures are stable and can be treated effectively by closed means. Each fracture must be addressed individually, taking into account the condition of the soft tissue envelope, the fracture characteristics, and the functional needs of the patient.
Mild (nonrotational) deformities do well with immobilization and protection while the fractures heal, but unstable or malrotated fractures benefit from surgical intervention.
Distal phalanx fractures are most commonly amenable to nonoperative treatment.
Results are good or excellent in more than 70% of extraarticular phalangeal fractures treated nonoperatively.1,5,7,10
Early motion is always desirable, but it is somewhat less important with closed treatment.
Immobilization beyond 3 weeks has been shown to increase stiffness12 and lead to worse outcomes.
Closed treatment
Less scarring to the extensor mechanism
Less ability to move early, unless the fracture is very stable
Minimal ability to hold a corrected deformity
Internal fixation
Greater scarring of the extensors, especially with a dorsal approach and a dorsal implant
Early motion essential
Greatest ability to hold the fracture in a stable, corrected position
If a fracture is incomplete, complete but nondisplaced, or impacted (such as the metaphysis at the base of the proximal phalanx), a short period (1 to 2 weeks) of splinting followed by buddy taping to the adjacent digit is appropriate (FIG 5).
A fracture that can be adequately reduced but is relatively unstable can occasionally be held reduced with a splint.
This has the advantage of avoiding a trip to the operating room and the possible complications of surgical fixation but requires close follow-up and serial radiographs to ensure that reduction is maintained (FIG 6).
FIG 5 • This fracture is stable because it is well aligned (on the AP and lateral radiographs) and that alignment does not change with motion. This fracture was treated with splinting for 2 weeks and buddy taping for 2 more weeks.
SURGICAL MANAGEMENT
When considering any surgery, it is necessary to balance the potential benefits of surgery with the risks of the procedure.
The goal of surgery is to restore alignment and to stabilize the fracture to a degree sufficient to begin early motion.
FIG 6 • A. This middle phalanx fracture shows apex volar angulation, which was easily reducible under digital block anesthesia, but the reduction was unstable and the deformity quickly recurred. B. A padded aluminum splint was fabricated to apply a three-point force to hold the fracture reduced. C. After 4 weeks of splinting, the fracture had healed and the splint was removed. By 6 weeks, motion was full, with mild discomfort with gripping.
Any phalangeal fracture with a significant injury to the soft tissue envelope has a worse prognosis.
Stable fixation (to the degree that it does not further compromise the soft tissues) and early motion assume a greater importance in phalangeal fractures with associated soft tissue injuries.
Patients with open fractures are treated with the appropriate intravenous antibiotic therapy.11
Once the decision is made to surgically intervene, the surgeon must decide which mode of fixation will best suit the fracture pattern (Table 1).
This decision is often made intraoperatively and is frequently based on the ability of the fracture to be adequately reduced closed.
Fractures that are reduced closed are stabilized externally with a cast or fixator or are held with Kirschner wires placed percutaneously.
Kirschner wiring and external fixation are techniques that, when appropriately applied, will result in acceptable outcomes without potential soft tissue surgical interruption and scarring.4
Open reduction and internal fixation with plates and screws will potentially provide stable fixation but without early mobilization could result in decreased range of motion.
Overly aggressive soft tissue stripping will cause extensor tendon adhesions, and bulky implants will affect extensor tendon balance and function.9
An algorithm can be used to aid in the decision-making process (FIG 7).
Methods
Percutaneous Wire Fixation
Closed reduction with percutaneous fixation can be used to treat the majority of unstable spiral fractures of the phalanges.
The technique is also suitable for transverse metaphyseal fractures, but it may be less suited for transverse diaphyseal fractures.
When the wires are inserted radial and ulnar to the extensor mechanism, percutaneous wire fixation offers the advantage of minimal disruption of the soft tissues in general, and the extensor mechanism in particular.
This technique is best suited for fractures less than 10 days old. After that time, early healing makes accurate closed reduction more difficult.
Kirschner wires provide less stable fixation than plates and screws and may restrict soft tissue gliding due to their prominence. This restriction of early motion may lead to increased stiffness.
Interosseous Wire Fixation
Interosseous wire fixation is more rigid than Kirschner wire fixation but requires open reduction and additional dissection to expose the bone surfaces.
This method of fixation is less bulky than a plate and, as such, is particularly well suited for fractures of the middle phalanx when percutaneous pinning is not possible.
Interosseous wiring works best with a transverse fracture. The wires provide compression to stabilize the fracture. Interosseous wiring will not work if the fracture is comminuted. Interosseous wiring is made more stable when it is combined with pin fixation and placed in a 90-degree configuration.
Lag Screw Fixation
Lag screw fixation is best suited for oblique and simple spiral fractures.
Lag screws can be used alone if the length of the fracture is greater than twice the diameter of the bone at the level of the fracture.
If the obliquity is less, a neutralization plate should be added.
Comminuted and transverse fractures are not amenable to lag screw fixation.
Contemporary lag screws are extremely low profile, making them an excellent fixation option in the phalanx, especially the middle phalanx.
Lag screw fixation is more rigid than Kirschner wire fixation, and unlike wires, the screws do not need to be removed.
Lag screws can be inserted percutaneously, but the procedure can be technically challenging.
Usually, an oblique fracture will be visualized best in the AP plane and the screws inserted from the lateral aspects.
Spiral fractures frequently require the screws to be placed in two planes.
Multiplanar screw fixation greatly increases the biomechanical stability (FIG 8).
Plate Fixation
Plate fixation is best suited for transverse fractures, short oblique fractures, periarticular metaphyseal fractures, and comminuted fractures, in which the plate serves as a bridge to maintain phalangeal length.
Midshaft, transverse fractures are fixed with a straight plate. At least two screws should be placed in either side of the fracture site with fixation of four cortices (FIG 9).
If close to the metaphysis, a T plate, a Y plate, or a condylar blade plate will allow improved fixation compared with a straight plate.
FIG 7 • Decision algorithm for the progression to open surgical treatment for phalangeal fractures and the subsequent treatment options for fixation.
FIG 8 • Lag screw fixation of a proximal phalanx. The placement of the screws prevents prominence to the extensor mechanism (A), and the multiplanar placement of the screws adds to the biomechanical stability of the fracture fixation (B).
Adding a lag screw across an oblique fracture, either through the plate or as an adjunct to plate fixation, will add to the rigidity of the construct.
Compression, obtained by eccentrically drilling one or more of the screws in the plate, will increase fracture stability.
Plate fixation requires more extensive soft tissue dissection and increases the risk of postoperative extensor scarring.
Immediate motion of the digits is essential to minimize the scarring.
Plates are more bulky and may lead to extensor mechanism imbalance, especially near the central slip insertion and on the middle phalanx.
Preoperative Planning
Preoperative posteroanterior, lateral, and oblique radiographs are essential.
Evaluation of these studies helps determine the plane of the fracture and the size of the fracture fragments, allowing the surgeon to choose the best surgical approach and the ideal fixation technique.
The surgeon must be certain that all potential implants are available. Surgical error can frequently be traced to implant availability problems.
Many sets include only one or two plates of a given size and shape. In the case of multiple digit involvement, extra plates and screws are helpful.
Intraoperative imaging using a mini fluoroscopy unit is essential, and its availability should be ensured.
The surgeon should plan for alternative approaches and means of fixation should comminution or soft tissue problems preclude the original plan.
Positioning
The patient is placed supine on the operating table with a radiolucent hand table attached.
A padded arm or forearm tourniquet is used for all cases.
Approach
The phalanx is most commonly approached laterally or dorsally. The exact approach used for open reduction is often based on the location of the fracture as it relates to the extensor mechanism (FIG 10).
The sagittal bands at the MP joint, the central slip insertion, and the triangular ligament should be preserved whenever possible (FIG 11).
Motion is necessarily delayed after surgery if these structures are incised and subsequently repaired.
A portion of the lateral band may be excised rather than repaired as part of the midaxial approach (FIG 12).
Longitudinal incisions in the midportion of the extensor tendon and especially in the midaxial interval between the extensor and the lateral band allow early motion.
At the middle phalanx level, a midaxial approach on the edge of the terminal tendon is preferred so that the tendon can be pulled to the side, exposing the bone (FIG 13).
The midaxial approach is also useful when using lag screw fixation, as the screws are usually inserted on the lateral aspect of the bone.
FIG 9 • Posteroanterior (A) and lateral (B) radiographs after plate and screw fixation of an unstable fracture pattern. The length of the screws is crucial to obtain bicortical fixation without prominence that will wear on the flexor tendon mechanism.
FIG 10 • The surgical approach to the proximal phalanx can be straight dorsal, through the extensor tendon (dashed line), or midaxial (dotted line), between the dorsal tendon and the intrinsic contribution. Care must be taken not to disrupt the central slip (CS) with the dorsal approach, and not to disrupt the sagittal bands (SB) with the midaxial approach. Thus, the dorsal approach is better suited for the more proximal fractures and the midaxial approach is better for the more distal fractures.
FIG 11 • A. Utilitarian dorsal curvilinear approach to the proximal phalanx. B. The extensor digitorum communis (EDC) tendon is fully visualized. C. A midline incision is made in the EDC, exposing the proximal phalanx, but protecting the sagittal band and the central slip insertion.
FIG 12 • A dorsolateral surgical approach to an index finger that demonstrates the sagittal fibers and extensor digitorum and lateral bands. The portion of the lateral bands outlined by the triangle may safely be excised.
FIG 13 • A. Utilitarian dorsal curvilinear approach to the middle phalanx with exposure of the extensor digitorum communis (EDC). B. A midline incision is made in the EDC, exposing the middle phalanx, but leaving the central slip and terminal extensor tendon insertions intact.
TECHNIQUES
PERCUTANEOUS KIRSCHNER WIRE FIXATION
Fracture Reduction
Before performing any reduction maneuver, obtain posteroanterior and lateral C-arm images for reference.
If the fracture is very close to the MP joint, a slightly oblique lateral view will show the fracture better by avoiding some of the overlap of the other MP joints.
Unstable spiral fractures of the phalanges are usually shortened, rotated, and angulated (TECH FIG 1A).
Begin the reduction by applying longitudinal traction.
This can be accomplished with direct traction on the digit. Use a moist gauze, fingertraps, or a pointed towel clip applied distal to the fracture.
While traction is applied, correct the rotational deformity (TECH FIG 1B). Any angular deformity is then corrected before placing a reduction clamp across the fracture.
Flexing the MP joint stabilizes the proximal P-1 fragment by tightening the collateral ligaments.
Apply a reduction clamp (a towel clip-like device with sharp points) across the fracture percutaneously to hold the reduction.
TECH FIG 1 • A. Unstable phalangeal fractures deform with shortening, rotation, and angulation. B. Longitudinal traction is applied first, and then the rotation and angulation are corrected. C. The bone is in the dorsal two thirds of the finger rather than in the middle. The neurovascular bundles are in the volar third and should, of course, be avoided when the reduction clamp is applied. D. When the fracture is reduced and compressed with the reduction clamp, the pins are drilled across the fracture site.
When considering the cross-sectional anatomy of the finger, remember that the bone lies in the dorsal two thirds, not in the midline (TECH FIG 1C). Thus, the clamp tips should enter the skin dorsal to the midlateral line.
Placing the clamp at a slight angle so that it is more perpendicular to the fracture will aid stability of the reduction through fracture compression.
Reduction can further be fine-tuned by twisting the clamp slightly when tightening.
Fracture Stabilization
After checking the reduction with the fluoroscope, drill the Kirschner wires across the fracture site until they gain purchase in the far cortex (TECH FIG 1D).
TECH FIG 2 • Posteroanterior and lateral radiographs showing a spiral proximal phalanx fracture treated with percutaneous pinning using the method described.
Usually 0.045-inch Kirschner wires are used in the proximal phalanx, although fixation in the small finger and in the more distal phalanges may require the smaller 0.035-inch Kirschner wire size (TECH FIG 2).
Diamond-tipped smooth Kirschner wires are preferred.
Crossed wires can be used to secure transverse fractures.
This method is useful for metaphyseal fractures (TECH FIG 3) and to stabilize middle phalanx fractures to avoid the need for plate fixation (TECH FIG 4).
Avoid distraction at the fracture site when using crossed wires.
TECH FIG 3 • This patient sustained a crush injury to the hand resulting in fractures of the middle, ring, and small fingers. The fingers were reduced by pinning them in flexion and passing the pins between the metacarpal heads rather than spearing the extensor tendons. This held the metacarpophalangeal joints in a flexed position once pinned. Active motion of the proximal and distal interphalangeal joints was started in the immediate postoperative period.
TECH FIG 4 • A. AP and lateral radiographs showing a displaced fracture of the middle phalanx of the middle finger and minimally displaced middle phalanx fracture of the ring finger. Note the importance of the lateral radiograph to assess the displacement of the middle finger fracture. B. The middle finger fracture was stabilized with crossed pins. The ring finger was fixed with a single pin to avoid displacement after early motion was started. C. The healed fractures after pin removal.
INTEROSSEOUS WIRE FIXATION
Exposure
Open reduction and fairly extensive fracture exposure is required for placement of the intraosseous wires, especially when using a dorsovolar wire.
Expose the fracture using either a dorsal or midaxial approach.
Place the bone in the “shotgun” position (apex dorsal) and gently elevate the soft tissues from the proximal and distal fragments 3 to 5 mm at the fracture site.
Drill transverse and anteroposterior holes 2 to 5 mm away from the fracture site using a 0.045 smooth Kirschner wire.
Fracture Reduction and Stabilization
Reduce the fracture and verify reduction through direct observation and with a mini C-arm.
Pass a 24-gauge steel wire through the transverse hole and a second wire though the anteroposterior holes.
Tighten the wire loops sequentially by pulling the wire away from the fracture and twisting slowly to stabilize and compress the fracture (TECH FIG 5).
Do not fully tighten the first wire until the second wire has been at least partially tightened.
Plan placement of the wire loops so as to lay them flat against bone and minimize soft tissue irritation.
If greater stability is required, drill a 0.035 to 0.045 smooth Kirschner wire obliquely across the fracture.
TECH FIG 5 • AP radiograph of a middle phalanx infected nonunion treated by débridement, squaring of the fracture ends, and 90-90 interosseous wiring.
LAG SCREW FIXATION
TECH FIG 6 • Screw size is determined by the bone size. Usually 1.5-mm or 2.0-mm screws are used in the proximal phalanx and 1.3-mm or 1.5-mm screws in the middle phalanx.
TECH FIG 7 • A. The tap drill for the chosen screw size is drilled from the near cortex, across the fracture and into the far cortex. The hole should be oriented so the drill crosses through the center of the bone and is centered in the far fragment as well. B. To gain a lag effect, the near cortex is opened to the outer diameter of the screw (overdrilled) so the screw threads will engage only in the far cortex, compressing the fractures as the screw is tightened.
Lag screws can be inserted percutaneously, but the procedure is technically challenging. Precise reduction of the fracture is the first priority and should not be sacrificed in an attempt to limit incision length.
Most often, the midaxial approach will provide the best exposure with the least amount of soft tissue stripping.
Screw size and number are determined based on fracture location, fracture characteristics, and the size of the bone fragments (TECH FIG 6).
When considering the use of multiple screws and screw location within the fragment, screws should be placed at least two diameters from the tip of the fracture and centered within the fragment.
The distance between screws should be at least two screw diameters.
The screws' orientation should be between perpendicular to the fracture line and perpendicular to the bone itself.
Screws placed perpendicular to the fracture provide maximal compression.
Screws placed more perpendicular to the bone provide axial stability.
Screws should always be drilled along a diameter (ie, crossing though the middle of the bone).
Reduce and hold the fracture with a clamp while the drill is advanced across the fracture site into the opposite cortex (TECH FIG 7A).
To gain a lag effect, create a gliding hole in the near cortex using a drill bit that is the same size as the screw's outer diameter (TECH FIG 7B).
Countersink the screw head to disperse forces as compression is applied and decrease screw head prominence.
Because the cortex is thin, countersinking is not recommended in the metaphysis.
Insert a self-tapping screw through the gliding hole and into the far cortex.
When the screw is tightened, the fracture is compressed.
Remain colinear with the screw to avoid deforming the soft titanium.
During final tightening, exert steady forward pressure and turn the screw slowly to avoid stripping the far cortex.
Repeat the procedure for additional screws (TECH FIG 8).
Alternatively, reduce the fracture with a clamp, then stabilize it with a Kirschner wire smaller than the core diameter of the screw. Place the first lag screw as described, then remove the Kirschner wire and insert the second screw through the predrilled Kirschner wire hole.
TECH FIG 8 • Preoperative (A) and postoperative (B) radiographs of a spiral fracture of the proximal phalanx fixed with two lag screws.
PLATE FIXATION
Plates can be placed either dorsally or laterally on the bone.
Lateral placement via the midaxial approach has the advantage of less extensor disruption and potentially fewer adhesions. Lateral plate placement effectively resists compressive forces.6
If the plate is applied to the dorsal surface, avoid overdrilling and placement of a long screw that may damage the flexor tendons.
Once exposed, clear the fracture site of soft tissue and reduce the fracture.
Fixation of Metaphyseal Fractures: T-Plate Technique
Provisionally place the plate on the bone using a pointed reduction clamp, a specialized plate-holding clamp, or a screw at one end of the plate.
Insert the screw in the middle of the T plate first, but before screw tightening align the plate perpendicular to the adjacent joint (TECH FIG 9A).
Perform the final fracture reduction and insert a screw on the other side of the fracture (TECH FIG 9B).
Assess the length, angulation, and most importantly the rotation clinically and radiographically.
Insert the remaining screws (TECH FIG 9C).
In the case of comminution, the plate is used to bridge the fracture fragments (TECH FIG 10).
TECH FIG 9 • A. The T plate is aligned perpendicular to the joint line and secured with a single screw. B. The distal portion of the fracture is brought into alignment and secured with one additional screw. C.Length, angulation, and rotational correction are all confirmed before insertion of the remaining screws.
TECH FIG 10 • A. Preoperative posteroanterior and lateral radiographs showing a comminuted index finger proximal phalanx fracture with significant shortening, angulation, and rotation, and a middle finger proximal phalanx fracture with reasonable alignment. The middle finger had a significant crush injury and a large volar wound. B. The index finger proximal phalanx fracture is fixed with a T plate, which is used to restore alignment, length, and rotation while bridging the fracture. Rather than risking additional vascular compromise to the middle finger with pins or open reduction, the relatively stable fracture of the middle proximal phalanx was treated by closed means. Active motion of both fingers was started 1 week after open reduction and internal fixation.
OTHER METHODS
Some authors have described using Kirschner wires as stacked intramedullary nails to secure phalangeal fractures. Intrafocal pinning is an excellent way to stabilize juxta-articular fractures of the proximal phalanx.3
By placing several wires along the canal, the fracture can be stabilized sufficiently to allow early motion.
Inserting the wires along the sides minimizes extensor tendon injury (TECH FIG 12A).
Other methods of fixation not commonly used for extraarticular phalangeal fractures include external fixation and bridging Kirschner wire fixation (TECH FIG 12B).
These rarely used methods are most useful for temporary fixation while allowing the soft tissue injuries to heal.
External fixation is more advantageous for border digits. For treatment of extra-articular phalangeal fractures, these fixators should not be placed across a joint if at all possible.
TECH FIG 11 • A. Intramedullary Kirschner wires can be stacked in the canal to provide intramedullary support to a phalangeal fracture. Wires are inserted from the sides to minimize extensor tendon damage. B. In the case of soft tissue damage with bone loss, a square U-shaped bend in a Kirschner wire can be used to temporarily maintain length while the soft tissue heals.
POSTOPERATIVE CARE
Postoperative care depends on the location of the injury and the bony fixation.
The best outcomes are achieved with restoration of anatomic alignment, respect for the soft tissue envelope, and early range of motion.
Treatment by an experienced hand therapist is a key component.
In the early phases, therapy consists of edema control and mobilization of adjacent digits and joints.
If adequate fracture stabilization is obtained, then mobilization of the involved digit is started almost immediately.
If fracture fixation is not ideal, active motion of the involved segment should be started no later than 3 to 4 weeks after surgery regardless of the radiographic appearance.
Protected mobilization should include removable splints that allow motion of adjacent digits and joints. As healing progresses, these splints are eliminated and buddy taping is employed.
Return to full activity is usually possible by 8 weeks.
OUTCOMES
Virtually all phalangeal fractures will heal in 4 to 6 weeks. Malalignment, especially rotation, and stiffness will diminish the outcome.
Most simple fractures treated with splinting, percutaneous pinning, or open reduction and internal fixation will regain near-full motion in 2 to 6 months, if the principles are followed and the proper intraoperative and postoperative techniques are employed.
In complex injuries where early motion is delayed because of concomitant soft tissue injury or prolonged splinting, the final outcome will be worse.
Sometimes hardware removal, tenolysis, and joint release are needed to improve motion.
Such procedures should be attempted only after tissue equilibrium has been reached (usually at least 4 months after the initial injury or surgery).
COMPLICATIONS
Loss of motion
Surgical: careful soft tissue handling with avoidance of prominent hardware
Postoperative: Elevation, ice, early motion of all noninjured joints, and controlled mobilization of injured segments as soon as possible are the best preventive measures.
If the problem persists and despite good therapy passive motion greatly exceeds active motion, tenolysis is a reliable method of treatment.
Malunion
Malreduction is common and, once secured with a plate and screws, difficult to correct. It is important to assess rotation on all phalangeal fractures before final fixation.
Accurate assessment is often difficult because the patient cannot make a full fist. Therefore, a reduction that was thought to be adequate in the face of restricted motion may prove inadequate once full motion is regained.
If significant enough, osteotomy should be considered.
Neurovascular injury while pinning a fracture
By observing the cross-sectional anatomy of the digit, damage to the neurovascular bundle can usually be avoided when inserting the wires.
Care must be taken when the wire passes through the second cortex, as it will usually be heading directly toward the neurovascular bundle.
Inserting the wires initially by hand until bone contact is made and using small open incisions may decrease the chance of injury when inserting the wire close to the neurovascular bundle.
Complex regional pain syndrome
Early recognition and treatment are essential.
A high index of suspicion is needed to identify key symptoms:
Swelling despite elevation and other edema-control efforts
Stiffness, especially in adjacent digits, despite efforts toward early mobilization
Color changes in the hand
Mottling or shiny appearance of the skin
Abnormal hair growth
Burning pain in the hand
Tendon rupture
Nonunion
Infection
Pin loosening and migration
Implant failure
Pain and symptoms from retained hardware
REFERENCES
1. Barton NJ. Fractures of the shafts of the phalanxes of the hand. Hand 1979;11:119–133.
2. Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop 1992;276:194–201.
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