Extra-articular Fractures of the Phalanges

17 Extra-articular Fractures of the Phalanges

David J. Shewring

Abstract

Diaphyseal fractures of the phalanges are common and the vast majority of these should be treated nonoperatively. Judicious fixation, when appropriate, has several advantages, but these fractures are unforgiving. The best chance of obtaining a good result is at the first surgical intervention and so the planning and execution of treatment should be undertaken by an experienced surgeon. Various methods of fixation can be employed including wires, screws, and plates and each of these methods has particular indications, advantages, and disadvantages. These are discussed within this chapter along with the treatment of specific configurations of fracture pattern affecting the phalangeal diaphysis. The aim in all cases should be to restore comfort, stability, and timely return to function, with a hand that is pain free, but sensate and with joints that are mobile but stable. For both operative and nonoperative treatment, the services of a team of skilled hand therapists are essential to achieve those goals. This chapter also discusses the management of particularly difficult situations such as delayed presentation of complicated fractures, severely comminuted fractures, and the management of malunion.

Keywords: fracture, phalanges, diaphyseal, internal fixation, nonoperative, hand therapy, lag screws, k-wires, malunion, comminution, osteotomy

17.1 Trauma Mechanism

The mechanism of the injury will dictate the configuration of the fracture and will often have a bearing on how the fracture is treated. A crush injury ( Fig. 17.1) may result in a comminuted but undisplaced phalangeal fracture. The periosteum is likely to be intact and therefore, despite the comminution, the fracture may be relatively stable. This will allow early mobilization after initial symptomatic treatment. Crush injuries may, however, be associated with more severe soft tissue damage and a higher incidence of complex regional pain syndrome (CRPS), and this will also influence management. A direct blow to the finger may result in a transverse fracture ( Fig. 17.2). The degree of displacement and comminution will reflect the energy of the injury. Such fractures tend to be unstable and may be open. An axial injury to a digit may result in an intra-articular fracture such as a die punch or pilon fracture with crushing and deformation of the cancellous bone (see Chapter 18). In the case of a spiral fracture, the trauma will have been indirect. The shape of the fracture and any deformity of the digit reflects the rotational nature of the force involved. These fractures often occur as the result of a fall, assaults, injury during contact sport, or as the result of the finger having become entangled in the reign of a horse, or dog lead. Displaced spiral fractures tend to be unstable, due to tearing of the periosteum and the configuration of the fracture.

Fig. 17.1 A comminuted but undisplaced fracture as the result of a crush injury.

Injuries caused by motorized tools such as mechanical saws or lawnmowers result in complex lesions including comminuted fractures and extensive soft tissue lacerations.

17.2 Classification

• Fractures of the proximal and middle phalanx

Metaphyseal

Diaphyseal

• Spiral and oblique fractures

• Transverse fractures

• Comminuted fractures

• Fractures of the distal phalanx

Shaft fractures

Tuft fractures

Fig. 17.2 (a–c) An unstable transverse fracture of the proximal phalangeal shaft fixed with a plate.

Fractures can be undisplaced, laterally displaced, angulated, rotated, or displaced in a combination of these.

17.3 Clinical Signs and Tests

Although a spiral fracture may appear undisplaced, this is relative, as the very fact that the fracture is visible on a radiograph will indicate some displacement.

The finger will need to be inspected carefully for signs of malrotation. This can be done by either gently flexing the digits, which will make any malrotation more obvious or by inspecting the relative orientation of the fingernails ( Fig. 17.3). If malrotation is present, it must be corrected or significant morbidity will result, as well as potential litigation. It is essential that all strapping be removed before the finger is examined or radiographs obtained. Failure to do so will not permit adequate examination and radiographs taken with strapping in place will also be inadequate.

17.4 Investigatory Examinations

Initial radiographs taken in the accident unit are often inappropriate. All too often a request for “X-ray hand” has been made and the resulting images include the whole hand rather than specific views of the relevant digit or joint. It is important that a specific request is made and that posteroanterior (PA) and true lateral views of the relevant digit or joint are obtained.

The advent of computerized radiology with the ability to rotate, expand, and change the contrast of images as well as accurate measurement of angles has made planning the treatment of small bone fractures significantly easier.

17.5 Concurrent Soft Tissue Lesions

Crush injuries may be associated with severe soft tissue damage and a higher incidence of CRPS, and this will influence management. Crush injuries to the fingertip are frequently open fractures, associated with a laceration to the nail matrix.

Severe fingertip injuries may be sustained when the fingers are inadvertently inserted into the path of the rotating blades of a lawnmower resulting in severely comminuted fractures of the phalanges, associated with significant soft tissue injuries, often with tissue loss.

Fig. 17.3 (a, b) Malrotation following fracture of a proximal phalanx. The orientation of the fingernails has been lost and the malrotation is enhanced by flexing the fingers.

17.6 Evidence

Fractures of the phalanges and metacarpals are the most common fractures of the skeletal system 1 and account for 10% of all fractures. Along with fractures of the carpal bones, they represent 55% of upper extremity fractures. Proximal phalangeal fractures are among the most common affecting the hand, accounting for 17% of hand fractures.

Although over the last few decades there has been an increased tendency to treat many of these fractures with internal fixation, the vast majority of hand fractures are stable and can (and should) be treated nonoperatively.² If surgical fixation is considered, then it must be appreciated that some hand fractures, particularly those affecting the proximal phalangeal shaft and intra-articular fractures, can be unforgiving.^3,4

The background to the injury is important and how the patient is treated will be influenced by numerous factors. The age, comorbidities, priorities, demands, occupation, and potential compliance of the patient must be established. What may be correct treatment for a phalangeal fracture in a 60-year-old professional violinist may not be appropriate for the same fracture in a 23-year-old player of contact sport.

It is imperative that the clinician does not fall into the trap of treating the radiograph rather than the patient that it relates to a sadly all too common scenario.

Many patients with hand fractures have a tendency toward irresponsibility, which must be taken into account. It is also worth considering that in most people, the hand, like the face, is the only part of the anatomy which is on display at all times and so cosmetic defects as the result of fractures (and their treatment) may be poorly tolerated.

At the cornerstone of treatment should be the services of skilled specialized hand therapists. During nonoperative treatment, they can, if necessary, splint injured digits leaving noninjured ones free. They can give patients advice on mobilization and correct care of the injured hand and their involvement will free up time for clinicians in busy clinics. Ideally, the therapists should be present in the trauma clinic so that plans can be formulated jointly and treatment plans discussed with surgeon, therapist, and patient present. If complex fixations are being attempted, then postoperative supervision by a specialized hand therapist is absolutely essential. If the therapists are encouraged to check matters at crucial junctures and bring patients back if they are concerned, then this will allow early discharge to their care.

Above all, it is essential to ensure that the patient is not made worse by the treatment, which is surprisingly commonplace. It is extremely depressing to encounter patients who would have had a far better outcome had they simply not come to a hospital.

“Do no harm.”

17.7 Author’s Favored Treatment Options

The vast majority of phalangeal fractures should be treated nonoperatively. Treated poorly, with a lack of respect and if the wrong tools are used in the wrong way and in the wrong hands, then the results may be catastrophic and irretrievable ( Fig. 17.4). Good or perfect results can be obtained, but these may be hard won, demanding careful planning with consideration of all the various methods in the surgical armamentarium. As the best and often only chance of obtaining a good result is at the first surgical intervention, these fractures should not be delegated to unsupervised more junior members of the surgical team. There is also no place for the surgical treatment of difficult hand fractures by the occasional hand surgeon. It is better to delay fixation by a few days until the best expertise is available. However, it is important to establish the exact amount of time that has elapsed between the date of the injury and the first consultation with the clinician who is going to provide the definitive treatment. There may have been delays, due to late presentation by the patient or tardy referral by the accident service.

When making a decision on what will be the most appropriate mode of treatment for a patient with a hand fracture, it is important to be aware of all the available options and to select that which is most likely to result in a good outcome. This may depend on many factors: the intrinsic qualities of the patient, the skillset of the surgeon, and the availability of facilities, equipment, and specialized hand therapy. Surgeons treating hand fractures should favor the method with which they are most familiar and competent. Consideration should also be given as to which technique utilizes the least health care resources.

Fig. 17.4 (a, b) A poorly fixed proximal phalangeal fracture, which has failed.

There are, of course, several advantages to judicious internal fixation. The anatomy can be restored and stability established. The fracture may be effectively “neutralized” so that efforts can be concentrated on the rehabilitation of the soft tissues, with mobilization of associated joints. It should also be remembered, however, that surgical fixation represents a further insult to an already injured hand and that this is cumulative. The aim in all cases should be to restore comfort, stability, and timely return to function with a hand that is pain free, but sensate and with joints that are mobile but stable.

If fixation is indicated, then there is a spectrum of available techniques, which can be tailored to each fracture. At one extreme would be a robust fixation, such as a plate ( Fig. 17.2). Although this would have the advantage of more stability and reliability, the increased trauma to the finger involved in its application could potentially compromise the result. At the other end of the spectrum would be a minimal fixation such as a single wire, inserted closed ( Fig. 17.5). Although this would have the advantage of having inflicted minimal added trauma to the hand, the fixation may not be robust enough to allow vigorous mobilization.

17.7.1 K-wires

K-wires do not provide a high degree of stability of fixation, but they can be used as what are effectively bone sutures. They provide augmentation of conservative treatment, making it more reliable. They can be used to maintain length and rotation to enable effective splintage and allow some movement.5–7 K-wires have some disadvantages. They may protrude, causing soft tissue interference to skin and adjacent joints.⁸ The pin site is vulnerable to infection and will need regular cleaning. They do not provide a stable enough fixation for vigorous mobilization and they usually need to be removed, although if they are left protruding through the skin, this can be done in clinic. When inserting more than one wire, it is important to avoid them crossing at the fracture site. If this occurs, then the fracture may be held in distraction resulting in a nonunion of the fracture. It is also important to avoid inserting them near the proximal interphalangeal (PIP) joint. This joint is particularly unforgiving (see Chapter 18) and stiffness will often ensue if this joint is compromised in any way ( Fig. 17.6). It is preferable and easier to insert the wires from the base of the phalanx. The wire can be guided between the metacarpal heads. The rim of the base of the phalanx can be felt with the wire and the wire inserted up the medullary canal, either up to the subchondral bone or to engage the lateral cortex ( Fig. 17.5).

They are, however, cheap and can be inserted quickly. When inserted closed, the integrity of the soft tissue envelope is preserved. Furthermore, if the fracture is highly comminuted and associated with significant soft tissue damage, as in the case of a crush injury ( Fig. 17.7), then K-wires provide an invaluable option of stability without the further soft tissue injury consequent to dissection.⁹