Joseph A. Rosenbaum
Hisham M. Awan
Fractures of the bones of the fingers typically secondary to trauma
Force applied to the affected bone exceeds its strength.
Mechanism of injury
Mechanisms of injury include crush; torsional, angular, and axial load; and traction.
High-energy mechanisms typically cause comminution.
Fracture may be part of a more severe overall injury pattern, including soft tissue injury to ligament, joint capsule, tendon, nerve, and/or vessels.
Fractures of phalanges and metacarpals are among the most common fractures.
Account for approximately 10% of all fractures
Common in laborers and athletes
Males are affected more than females.
Typically caused by trauma, either direct or indirect
Rarely can be pathologic fractures with minimal or no antecedent trauma
Presentation may be delayed—Patients may dismiss as a “jammed finger” or sprain.
Often overlooked initially in polytrauma cases
Assess for edema, angular deformity, rotational deformity, and quality of soft tissues.
Assess sensation and capillary refill distally.
Assess the other digits as well as the hand and wrist.
Test for tendon function individually for each finger (flexor digitorum superficialis, flexor digitorum profundus, extensor digitorum communis).
Obtain finger radiograph initially if fracture is suspected.
Proximal, middle, distal phalanx (P1, P2, P3)
Open versus closed (Nail bed injury with concomitant P3 fracture is considered an open fracture.)
Intra-articular versus extra-articular
Stable versus unstable fracture pattern
Comminuted versus simple (Simple are generally more stable.)
Transverse versus oblique (Transverse are more length-stable.)
Angulation (P1 tends to be apex volar, P2 apex dorsal.)
Presence or absence of foreign bodies
Middle phalanx fractures
Distal phalanx fractures
Emergency room management
Proximal interphalangeal (PIP) stiffness is a major concern; early mobilization is beneficial.
Extensor mechanism is intimately attached to proximal phalanx, which can lead to adhesions and stiffness with internal fixation.
Transverse fractures tend to angulate, whereas long oblique or spiral fractures tend to lead to malrotation.
Proximal phalangeal fractures tend to displace with apex volar because of the interossei pulling the proximal fragment into flexion and the central slip pulling the distal fragment into extension.
Fracture geometry and stability are often used to help determine stability.
Immobilization is generally brief (less than 3 weeks) before transition to buddy taping and restarting range of motion (ROM).
Proximal phalanx fractures
Closed, displaced, reducible nonarticular fractures that are stable after reduction
Reduce with metacarpophalangeal (MCP) joints flexed 70° to 90° and cast with forearm-based dorsal blocking splint with MCP in flexion and interphalangeal joints in full extension.
Acceptable reduction features
▲ Greater than 50% cortical apposition
▲ No malrotation
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