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Extra-articular Christian Dumontier, MD,

PhD

phalangeal fractures Guadeloupe

www.diuchirurgiemain.org
Epidemiology
Out of 1.5 million hand and forearm fractures, 23% were phalangeal fractures
(Chung).
50% of 72,000 hand fractures were phalangeal fractures (Feehan).
Distal phalanx fractures and tuft fractures constitute almost 50%.
70% of all phalangeal and metacarpal fractures occur in patients age 11-45
years. Sports-related injuries were the most common cause in individuals aged
10-29 years.
Lost productivity associated with phalangeal fractures exceeds $2 billion per year

Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg
2001;26:90815.
Feehan LM, Sheps LM, Samuel B. Incidence and demographics of hand fractures in British Columbia, Canada: a population-
based study. J Hand Surg 2006;31:106874.
Van Onselen EB et al. Prevalence and distribution of hand fractures. J Hand Surg Br 2003;28(5):4915.
Epidemiology of phalangeal fractures

Prospective study, 924 fractures


Mechanism: Crush 62%; Fall 12%; Saw 9 %; Cut 6%,
Fx geometry: Oblique/spiral 31%; Transverse 29%,
comminuted 29%,

Ip WY et al. A prospective study of 924 digital fractures of the hand. injury 1996;27:279-285.
Epidemiology of phalangeal fractures

Ip WY et al. A prospective study of 924 digital fractures of the hand. injury 1996;27:279-285.
Anatomy
A proximal base, a central diaphysis, and a distal
head
Phalanges are flattened in the dorso-palmar
plane
Proximal and middle phalanges have a
palmar concavity
In contrast with the metacarpals, the bases of all
the phalanges and not the heads develop as
metaphyses.
The distal portion of the distal phalanx is
referred to as the tuft.
Relative lengths:
Tip of the index base of the nail of the
middle
Tip of the ring mid-aspect of the middle
finger nail
Tip of the small DIP of the ring.
1st TAKE HOME MESSAGE
Skeletal stability is needed to allow the digits to act as segmented
lever arms
Tendon mechanism relies on correct length, rotation and angulation
of the phalanges
Dynamic relationship between form and function
Nonsurgical management consists of buddy taping w/wo protective
splinting, for 4 to 6 weeks, with initiation of ROM exercises no later
than 3 to 4 weeks.
Protective splints should include 1 joint proximal and distal to the
fractures at a minimum.
Strickland JW et al. Phalangeal fractures: factors influencing digital performance. Orthop Rev
1982:39-50
The devil is in the detail
Extra-articular fracture of distal
phalanx
Fractures of distal phalanx

50% of all phalangeal


fractures
Crushing injuries
Problem (and solution) is at the
nail (see lectures of Dr Carms
at www.diuchirurgiemain.org)

Wang W et al. Stability of the distal phalanx fracture - A biomechanical study on the importance of the nail and the influence of
fixation by crossing Kirschner wires. Clin Biomech 2016;37:137-40.
Tuft Fractures
Tuft fractures are often
comminuted but inherently stable
due to the dense fibrous
connections of the soft-tissues
They are very painful ++
They frequently end up as a stable
fibrous non-union
A short (1014-day) period of
immobilization of the middle and
distal phalanges will provide
symptomatic relief and support of
the fracture.
Diaphyseal Fractures of the distal phalanx

Diaphyseal fractures are either


transverse or longitudinal
Frequently stable after
reduction otherwise fixation
Needle, K-wire, screw
Extra-articular or through
the DIP joint)

Chen F et al. Fractures of the distal phalanx. Op Techn Orthop 1997;7(2):107-115


Basal fractures of distal phalanx

Tends to displaced with a volar


apex due to the pull of the FDP
The tuft of the distal phalanx
lies just volar to the nail bed.
The starting point for a
retrograde K-wire is just volar
to the hyponychial fold
Prunieres G. Traitement des fractures instables de la phalange distale par brochage extra-
articulaire de linterphalangienne distale : propos de 12 cas. HSR 2016;35:330334
Is one technique superior ?

172 patients with DP fractures (2007-2013)


141 treated conservatively (82%)
31 patients had surgery (12 K-wire vs 21 screw fixation of which 50% required
removal)
Healing for screw was 100% vs 83% for K-wire.
Time to union 2.4 months for screw vs 4.1 months for K-wire
ROM for screw fixation was 60 vs 45 with K-wire (p<0,05)
ROM for non-transarticular K-wire (46) similar to transarticular K-wire
(44).

Robyn Aid Siew H et al. A Comparison of K-Wire Versus Screw Fixation on the Outcomes of Distal Phalanx Fractures. J Hand
Surg Am. 2015;40(11):2160-2167.
Seymours lesion
The Seymour fracture is a complete physeal
separation that occurs from a hyperflexion injury.
The extensor tendon remains attached to the
proximal ephiphyseal fragment while the
unopposed flexor digitorum profundus (FDP)
tendon pulls the remainder of the distal pha- lanx
into flexion.
A transverse laceration of the nail bed occurs, and
the avulsed nail plate lies superficial to the
proximal nail fold.
Frequently unstable
Complications

70% of 110 patients still complain at 6


months (chronic pain, cold
hypersensitivity, numbness) and 55%
were not united
Nail abnormalities was seen in 39% of
patients
Infection is prevented by lavage and
debridement (not antibiotics) - Metcalfe

Metcalfe D. et al. .Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg.
2016;41E(4):423-30
DaCruz DJ, Slade RJ, Malone W. Fractures of the distal phalanges. J Hand Surg Br. 1988;13(3):350-352
Extra-articular fractures of middle
and proximal phalanges
Clinical evaluation

In the uninjured hand, all nail


plates are coplanar both with
the digits extended and flexed.
Clinical evaluation

Rotation is evaluated on
the fingernail orientation
in extension, and during
finger flexion as flexed
finger are directed to the
scaphoid tubercle +++
Fractures of middle phalanx
Diaphyseal fractures of the middle phalanx

The most frequent (53%)


Fracture patterns: transverse,
oblique (short & long), spiral &
comminuted
Angulation depends of the
location of the fracture line to
the insertion of the FDS
Treatment of middle phalanx #
Closed reduction and
immobilisation in the intrinsic plus
position for most fractures +++
Indications for surgery includes
Angulation > 10 in any plane
> 2 mm shortening
< 50% bony apposition
Any rotation deformity
Long oblique or spiral Fx patterns
with offset
Open fractures
a non-displaced fracture treated conservatively with a 4 weeks splint.
Some extension lag is present at early follow-up
Two examples of malunion with persistent rotational deformity (left) and recurvatum (right)
Surgical treatment of P2 #
Many techniques: K-wires (0,045 inch) under
fluoroscopic control are most often used but need some
immobilisation (low cost, minimal soft-tissue
compromise, versatility,)
Drive the sharp end of the K-wire through the far
cortex, through the skin, truncate the sharp tip, and
draw it back to the appropriate length to minimize
symptomatic irritation of soft tissues by the sharp point
18% of complications in a series of 137 patients/422
pins
Pin tract infection 7%
Aseptic loosening 4%
Loss of reduction 4%

Botte MJ et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. CORR
1992;276:194-201.
Crossed K-wires

26 cases
3 weeks immobilisation then
buddy taping
86% total ROM within 8 weeks

Green DP et al. Closed reduction and percutaneous pin fixation of fractured phalanges. JBJS
1973;55A:1651-1654
Crossed K-wires for neck fracture ending as a non-union
Tension Band technique according to Lister
Intra-medullary nailing

40 cases
Minimal residual angulation(<
10) and shortening (1,5 mm)
ROM was 220

Orbay JL et al. The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonblocking and locking
intramedullary nails. Hand Clin 2006;22:279-286.
Screws (oblique, spiral) and plates (transverse pattern)

Surgical approach can be mid lateral


or mid axial
At least two screws
Screws proved superior to K-wire for
complications (7 vs 31%), shorter
immobilisation time (2 vs 4 weeks)
and return to work (6,2 vs 10,1 wk off)
Plates had an incident of 57%
complication

Page SM et al. Complications and range of motion following Plate Fixation of Metacarpal and Phalangeal Fracture. J Hand
Surg 1998;23A:827-832.
Middle phalanx base fractures
Increase probability of stiffness
due to proximity of the PIP
joint and fracture location
within the zone 2 of the flexor
tendon
Reduction requires MCP
flexion, PIP Extension
(stabilisation of the proximal
fragment), traction (to obtain
length), extension of distal
fragment
Fractures of the proximal phalanx
Displaced fractures and biomechanical consequences

Proximal phalanx is mostly


devoid of any soft tissue
attachments
But it is surrounded by mobile
tendons and sheath
Male predominance (2/3 of
patients), mean age of 34.4
years, mostly little finger (46%)

Desaldeleer-Le Sant AS et al. Surgical management of closed, isolated proximal phalanx fractures in the long fingers:
Functional outcomes and complications of 87 fractures. Hand Surgery and Rehabilitation (2017-in press).
Can you name all of the structures ?
Displaced fractures and biomechanical consequences

Displacement is with volar apex due to


the pull of the interossei and tension on
the extensor tendon
Angular malunion of 16, 27 and 46
volarly result in PIP extensor lag of 10,
24 and 66 respectively

Vahey JW et al. Effect of proximal phalangeal fracture deformity on extensor tendon function. J Hand Surg 1998;23A:673-681
Non-Operative treatment

Main treatment in non


displaced and stable fractures (<
15 of volar angulation, < 10
angulation in the coronal plane,
< 4 mm shortening, no clinical
malrotation)
Motion of PIP should starts
before 4 weeks (82% full motion
before 4 weeks, 66% after 4
weeks)

Strickland JW et al. Phalangeal fractures: factors influencing digital performance. Orthop Rev 1982:39-50
Non-Operative treatment

Intrinsic position
(wrist extension,
MCP flexion
70-90, PIP in
extension)

Thomine JM, Gibon Y, Bendjeddou MS, Biga N. Functional brace in the treatment of diaphyseal fractures of the proximal
phalanges of the last four fingers. Ann Chir Main 1983;2:298306.
NonOperative treatment
Blocking the MCP joints in flexion +
actively flexing the PIP joints advances the
extensor hood
Two-thirds of the proximal phalanx is
embraced. The fracture is compressed, and
there is stabilization of axis and rotation.
With active finger flexion, compression
forces are transmitted to the palmar cortex
of the proximal phalanx, and stiffness of
the PIP joint is prevented.
Limitation: Difficult to control reduction on X-rays.
A cadaveric study revealed that maximum stability
By means of semirigid fixation to an to proximal phalangeal fractures was in the proximal
adjacent finger (buddy loop), the injured 6- to 9-mm range at the base of the proximal phalanx
finger is guided and passively moved. due to the contribution of the joint capsule, collateral
ligaments, accessory collateral ligaments,
78 cases: 86% had full motion interosseous muscles, and volar (palmar) plate.

Figl M et al. Results of dynamic treatment of fractures of the proximal phalanx of the hand. J Trauma 2011;70:852-856.
Widgerow AD, Ladas CS. Anatomical attachments to the proximal phalangeal basea case for stability. Scand J Plast Reconstr Surg Hand
Surg. 2001; 35(1):8590
Improvement with Thomine technique

Thermo-malleable splints
Improvement with Thomine technique

No need to immobilize the wrist (LuCa) - 66 pts, 75 #, no


difference
97 patients (103 fractures) treated with Zancolli brace at
> 1-year follow-up, 75% excellent or good results. No
nonunion.
The 25% poor results were older (53.1 vs 35.1 years) and
comply poorly with the rehabilitation program.

Fok MW et al. Ten-year results using a dynamic treatment for proximal phalangeal fractures of the hands. Orthopedics. 2013
Mar;36(3):e348-52.
Franz T et al. Extra-Articular Fractures of the Proximal Phalanges of the Fingers: A Comparison of 2 Methods of Functional,
Conservative Treatment. J Hand Surg 2012;37A:889898
Operative treatment
Percutaneous pinning (extra or intra-articular)
Percutaneous lag screws
ORIF with pins and screws
Intra-osseous wiring
Tension band fixation
Intramedullary fixation (including headless screws)
Plate fixation
Reduce fractures with pointed
reduction forceps or towel
clips while applying
longitudinal traction, obtain
bicortical purchase with each
pin when possible, be
perpendicular to fracture lines
when possible, and maximize
the spread of K-wires

A clamp, an image intensifier and 0,045 K-wires (1 /1,2 mm)


Clinical results can be satisfactory

Cross-pinning leaving MCP and PIP free obtained 100% healing


and 85% of 35 patients > 220 TAM (al-Qattan)
18% complication rate in pin fixation (infection, pin loosening,
and nonunion) - Botte.

al-Qattan MM. Displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers in industrial
workers: reduction and K-wire fixation leaving the metacarpophalangeal and proximal interphalangeal joints free. J Hand
Surg Eur Vol. 2011;36(7):577-83.
Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and
wrist. Clin Orthop Relat Res. 1992; (276):194201.
Technical variation

Pelissier P. et al. Brochage des fractures de phalanges en va-et-vient foyer ferm. Chirurgie de la main 34 (2015) 2426
A combination of
Thomine position of
reduction and trans-
articular pinning to
improve reduction
Good to excellent results can be obtained with k-wires although the rate of
complications is still high
ORIF: Surgical approach

Dorsal or mid-axial
Preserve dorsal veins and paratenon to minimize the
risk of adhesion and extensor lag
Interval between central slip and lateral bands is
dissected (some resect a lateral band)

Field LD et al. Midaxial approach to the proximal phalanx for fracture fixation. Contemp Orthop 1992;25:1337.
Jupiter JB et al. Fractures of the metacarpals and phalangeals. In: Chapman MW, editor. Operative orthopedics.
Philadelphia: JB Lippincott; 1988. p. 123550.
ORIF: Screws or plate

Biomechanically, 3 screws have


similar torsional strength to
plate fixation.
The screw diameter should be
less than one-third of the length
of the fracture line, and multiple
screws are placed to maintain
stability
Clinical case

30 years old plumber


Felt on his hand and sustained index and
middle finger fractures
For unknown reason the previous surgeons
only fixed the middle finger
What would you recommend at 2 weeks ?
Plate fixation to allow for immediate motion - Excellent results at FU
Complications are not rare
52% complication rate in 64 # treated with plates (CPRS,
Total ROM < 180, infection, delayed union/nonunion,
implant failure) - Kurzen
64% complication rate with plates (extensor lag > 35,
ROM < 180, infection, plate prominence, tendon
rupture) - Page

Kurzen P et al. Complications after plate fixation of phalangeal fractures. J Trauma. 2006; 60(4):841843
Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal
fractures. J Hand Surg Am. 1998; 23(5):827832
Minor complication with extensor lag due to malunion
Severe malunion
Neck Fractures
Frequent in children, rare in adults
Non-displaced # are treated with
the IP joints in extension for 3 weeks
Displaced # are reduced and either
splint or fixed with K-Wires
Beware during reduction: gradual
longitudinal traction and pushing
gently in a palmar direction.
K-wires are driven through the base
of the proximal phalanx
92% of normal TAM in 10 patients

al-Qattan MM. Phalangeal neck fractures of the proximal phalanx of the fingers in adults. Injury. 2010;41(10):1084-9.
Neck fractures in children
Type I: Nondisplaced nonoperatively in a
splint for 4 weeks.
Type II: Displaced fractures with persistent
bone-to-bone contact (70% of cases).
These fractures are unstable and maintaining
reduction often requires K-wire fixation.
If present late with radiographic evidence of
some healing, do not try to manipulate as
these fractures remodel quite well in young
children.
Type III: Completely displaced fractures with
rotation of the distal fragment up to 180
ORIF with K-wire.
Saw injury (open fracture with
soft-tissue lesions) treated with
External fixator, cement
intercalary graft according to
Masquelets technique and
local flap
New technique ?

Headless screws through the


articular cartilage of the PIP
joint (del Pinal)
The screw hole represents
around 20% of the articular
surface.
ROM 243 (150 to 270 )

Del Pinal F. Minimally Invasive Fixation of Fractures of the Phalanges and Metacarpals With Intramedullary Cannulated
Headless Compression Screws. J Hand Surg Am. 2015;40(4):692-700.
Is there a technique which is superior ?

No
Literature trends are for better functional outcomes and
earlier finger mobilization for screw, plate and pin
fixation, in that order
Conclusion - 2nd take home message

Do not Harm !
Conservative treatment gives good results with a very
low rate of complication and should be preferred
However, PIP joint should be mobilized at 3-4 weeks,
not later. If impossible with conservative treatment,
fixation is needed
Screws fixation seems to give the better results