Plastic Surgery for Phalangeal Fracture and Dislocation

Plastic Surgery for Phalangeal Fracture and Dislocation

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Phalangeal fractures are common injuries that may significantly affect hand function if not managed appropriately. Closed treatment has been the mainstay of treatment for reducible and stable fracture configurations. Unstable or irreducible fracture patterns require open or closed reduction and fixation. Percutaneous pinning allows the conversion of more unstable fracture patterns to stable configurations capable of tolerating early motion. Mini fragment screws and plates assist in the management of complex phalangeal fractures. [1, 2] For information on fractures of all kinds, visit the Medscape Fracture Resource Center.

Injuries to the phalanges can result in significant loss of hand function. Even the mild “jammed” finger, if not diagnosed and treated promptly, can lead to decreased motion and a poor outcome. This is especially true with injuries to the proximal interphalangeal joint (PIPJ). Fractures of the phalanges, if unstable, need fixation secure enough to allow early motion to prevent adhesion formation and permanent stiffness. [3]

Because many injuries to the phalanges go unreported, defining a true incidence is difficult. Fractures of the phalanges are surely among the most common in the entire skeleton and may account for as many as 10% of all fractures. A study by Karl et al indicated that phalangeal hand fractures are the second most common upper extremity fractures in the United States, at 12.5 per 10,000 persons annually (behind only distal radius and ulna fractures, at 16.2 per 10,000 persons). The study also found that phalangeal fractures were the most common upper extremity fractures in males and in persons aged 35-49 years. Moreover, the incidence of phalangeal and metacarpal fractures, unlike other upper extremity fractures, was seen to decrease with increasing socioeconomic status. [4]

Fractures of the proximal phalanx are the most common phalangeal fractures, followed by fractures of the distal phalanx and then the middle phalanx. The small finger accounts for more than one third of all hand fractures, with an even distribution among the remaining 4 digits. [5]

Fractures and dislocations of the phalanges occur from various mechanisms. In younger patients, these injuries are more likely to be sports-related, while older patients are likely to be injured by machinery or falls. [6, 7] Crush injuries are common at the distal phalanx, while the PIP joint is usually damaged by an axial blow to the finger.

Stability of phalangeal fractures depends on location, fracture orientation, integrity of the periosteal sleeve, and degree of initial displacement. Distal tuft fractures are usually stable despite comminution. Unicondylar and bicondylar fractures involving the interphalangeal joints are inherently unstable. Displaced fractures involving the diaphyses of the proximal and middle phalanges are also unstable secondary to the pull of the intrinsics and flexor tendons. [8] Fractures with an intact periosteal sleeve and no initial displacement are usually stable.

Clinical presentation of finger fractures and dislocations depends primarily on the mechanism of injury. Crushing injuries to the fingertip commonly involve injuries to both the nail bed and the underlying distal phalanx. Injuries at the interphalangeal joints usually present with swelling, ecchymosis, and decreased motion. Any areas of tenderness or crepitus should be palpated. Loss of length or of normal knuckle contour may be indicative of fracture shortening or angulation. [9] Deformity may also be present at the joint as well as in the diaphysis of a displaced, unstable fracture.

Transverse fractures in the proximal phalanx assume an apex volar deformity secondary to pull of the intrinsic tendons on the proximal fragment, causing it to flex, and the extensor tendon on the middle phalanx, causing it to hyperextend. Unicondylar fractures at the head of the proximal phalanx are common athletic injuries and can often be missed because the athlete can bend his or her finger after the initial injury. Patients present with a history of dislocation reduced by a trainer and present much later if they continue to experience pain and deformity. [10]

Fractures of the middle phalanx angulate with the distal fragment dorsally if the fracture is distal to the flexor digitorum sublimis (FDS) insertion and palmarly if the fracture is proximal to the FDS insertion. Distal phalanx fractures, usually secondary to a crush injury, generally do not displace because both the flexor and extensor tendons insert on the base of the distal phalanx. The nail plate may also provide some support to preserve alignment of the fractured distal phalanx. [9] Care must be taken to evaluate the digit for rotational deformity as well. This is best accomplished by flexing the fingers and viewing the nails on end. Subtle overlap may vary from patient to patient; thus, comparison with the contralateral hand can be very helpful.

Classification of these fractures is often done using fracture pattern (transverse, oblique, spira, comminuted), fracture location (head, neck, shaft, intra-articular), and the extent of soft tissue injury (open vs closed). [9]

Phalangeal fractures that are nondisplaced or stable following reduction are amenable to closed treatment with splinting and early rehabilitation. Indications for operative treatment of phalangeal fractures include the following:

Open fractures

Irreducible fractures

Unstable fractures

Failed closed reductions

Displaced intra-articular fractures

Relative indications include the following:

Multiple fractures

Fractures with bone loss or associated tendon injury [9]

Fractures with associated tendon injury [9]

In general, management of soft tissues is the first priority. Open wounds are common and are an indication for irrigation and debridement. Management of wounds is aided by fracture fixation. Treat fractures with the least invasive method that results in a stable configuration as this allows for early rehabilitation. If stability cannot be achieved or maintained following reduction, some form of fixation is required. The form of fixation chosen should involve the minimum amount of soft-tissue disruption as surgical exposure increases the likelihood of postoperative scar formation between tendon and bone.

There are few places in the body where function and anatomy are as closely intertwined as in the finger. Injuries and subsequent scar formation can upset the delicate balance that normally exists, particularly at the PIPJ and extensor apparatus. Anatomic considerations are based on the level of injury.

Distal phalanx: Terminal extensions of the flexor and extensor tendons insert into the base of the distal phalanx. These tendons can rupture at their insertion or can avulse a fragment of bone. Tuft fractures are commonly associated with injury to the overlying nail bed.

Distal interphalangeal joint (DIPJ): The head of the middle phalanx consists of two condyles that articulate with the base of the distal phalanx. With an axial load, one or both of the condyles may fracture. A closely adherent volar plate provides significant stability. Radial and ulnar collateral ligaments provide resistance to stresses in the coronal plane. [11]

Middle phalanx: Sublimis tendons insert along a broad expanse on the volar aspect of the proximal half of the phalanx. The profundus tendon is held tightly in the flexor sheath by the important A4 pulley at the mid portion of the phalanx. The middle phalanx region also contains additional cruciate pulleys (C2 and C3) that are located proximal and distal to the A4 pulley, respectively. On the extensor side, the central slip inserts into the base of the middle phalanx. Lateral bands join over the distal portion of this phalanx to form the terminal extensor tendon. The two lateral bands are stabilized by the triangular ligament, located just distal to the central slip insertion, which prevents volar subluxation of the lateral bands.

Proximal interphalangeal joint (PIPJ): Anatomy at the PIPJ is similar to the DIPJ. The volar plate covers a broad expanse over the joint and is the main stabilizer to joint dislocation. Collateral ligaments are larger at the PIPJ and consist of proper and accessory components.

Proximal phalanx: Sublimis and profundus tendons run together in the flexor sheath at this level. The A2 flexor pulley covers most of the proximal half of the phalanx while the C1 pulley is located more distally. The extensor digitorum communis tendon runs the length of the phalanx and is stabilized by oblique and transverse fibers of the intrinsic apparatus. The lateral bands run from a lateral and volar position at the proximal aspect of the phalanx to a more dorsolateral position at the level of the PIPJ.

No absolute contraindications exist in the management of these injuries. Studies have shown that even in the face of extensive soft tissue damage (open fractures), achieving solid internal fixation allows early mobilization and is of great importance. [12, 13] Relative contraindications include the use of internal fixation in a reduced and stable fracture or plating a fracture that can be managed with a less invasive fixation technique.

Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg [Am]. 2006 Oct. 31(8):1349-54. [Medline].

Haase SC, Chung KC. Current concepts in treatment of fracture-dislocations of the proximal interphalangeal joint. Plast Reconstr Surg. 2014 Dec. 134 (6):1246-57. [Medline].

Johnson D, Tiernan E, Richards AM, Cole RP. Dynamic external fixation for complex intraarticular phalangeal fractures. J Hand Surg [Br]. 2004 Feb. 29(1):76-81. [Medline].

Karl JW, Olson PR, Rosenwasser MP. The Epidemiology of Upper Extremity Fractures in the United States, 2009. J Orthop Trauma. 2015 Aug. 29 (8):e242-4. [Medline].

van Onselen EB, Karim RB, Hage JJ, Ritt MJ. Prevalence and distribution of hand fractures. J Hand Surg Br. 2003 Oct. 28 (5):491-5. [Medline].

De Jonge JJ, Kingma J, van der Lei B, Klasen HJ. Phalangeal fractures of the hand. An analysis of gender and age-related incidence and aetiology. J Hand Surg [Br]. 1994 Apr. 19(2):168-170.

Chen F, Kalainov DM. Phalanx fractures and dislocations in athletes. Curr Rev Musculoskelet Med. 2017 Mar. 10 (1):10-6. [Medline]. [Full Text].

Shewring DJ, Trickett RW, Smith A. Fractures at the junction of diaphysis and metaphysis of the proximal phalanges in adults. J Hand Surg Eur Vol. 2018 Jan 1. 1753193418766973. [Medline].

Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. Mar-Apr 2000. 8(2):111-21.

Geissler WB. Operative fixation of Metacarpal and Phalangeal Fractures in Athletes. Hand Clinics. Aug 2009. 25(3):409-421.

Yesilada A, Sevim ZK, Irmak F, Sucu DO, Tatlidede HS. Middle phalangeal distal condylar fracture remodelling in children: a case report. Acta Chir Plast. 2012. 54(1):23-5. [Medline].

O’Sulluvan ST, Limantzakis G, Kay SP. The role of low-profile titanium miniplates in emergency and elective hand surgery. J Hand Surgery [Br]. June 1999. 24(3):347-349.

Bannash H, Heermann AK, Iblher N, Momeni A, Schulte-Mönting J, Stark GB. Ten years stable internal fixation of metacarpal and phalangeal hand fractures- risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures. J of Trauma. Mar 2010. 68(3):624-628.

Tan JS, Foo AT, Chew WC, Teoh LC. Articularly placed interfragmentary screw fixation of difficult condylar fractures of the hand. J Hand Surg Am. 2011 Apr. 36(4):604-9. [Medline].

Ouellette EA, Freeland AE. Use of the minicondylar plate in metacarpal and phalangeal fractures. Clin Orthop Relat Res. Jun 1996. 327:38-46.

Schatzker J. Screws and plates and their application. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internal fixation: Techniques Recommended by the AO-ASIF Group. 3rd. New York, NY: Springer-Verlag; 1991. 179-290.

Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg. May 1998. 23A(3):368-380.

Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg [Am]. Nov 1986. 11(6):850-8.

Calfee RP, Kiefhaber TR, Stern PJ. Hemi-Hamate Arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg. Sep 2009. 34A(7):1232-1241.

Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilon fractures of the proximal interphalangeal joint. J Hand Surg [Am]. Sept 1991. 16(5):844-50.

Creighton JJ Jr, Steichen JB. Complications in phalangeal and metacarpal fracture management. Results of extensor tenolysis. Hand Clin. Feb 1994. 10(1):111-16.

Freeland AE, Hardy MA, Singletary S. Rehabilitation for proximal phalangeal fractures. J Hand Ther. Apr-Jun 2003. 16(2):129-142.

Jupiter JB, Koniuch MP, Smith RJ. The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg [Am]. Jul 1985. 10(4):457-66.

Freeland AE, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin. Aug 2006. 22(3):341-55.

Gross MS, Gelberman RH. Metacarpal rotational osteotomy. J Hand Surgery [Am]. Jan 1985. 10(1):105-108.

Al-Qattan MM, Al-Motairi MI, Al-Naeem HA. The diaphysial axis – metacarpal head angle in the management of fractures of the base of the proximal phalanx in children. J Hand Surg Eur Vol. 2013 Nov. 38(9):984-90. [Medline].

Lankachandra M, Wells CR, Cheng CJ, Hutchison RL. Complications of Distal Phalanx Fractures in Children. J Hand Surg Am. 2017 Jul. 42 (7):574.e1-.e6. [Medline].

Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg [Am]. Sep 1998. 23(5):827-832.

Chow SP, Pun WK, So YC, Luk KD, Chiu KY, Ng KH, et al. A prospective study of 245 open digital fractures of the hand. J Hand Surg [Br]. May 1991. 16(2):137-140.

Pritsch T, Rizzo M. Reoperations following proximal interphalangeal joint nonconstrained arthroplasties. J Hand Surg Am. 2011 Sep. 36(9):1460-6. [Medline].

Onishi T, Omokawa S, Shimizu T, Fujitani R, Shigematsu K, Tanaka Y. Predictors of Postoperative Finger Stiffness in Unstable Proximal Phalangeal Fractures. Plast Reconstr Surg Glob Open. 2015 Jun. 3 (6):e431. [Medline].

Del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Regalado J. Results of osteotomy, open reduction, and internal fixation for late-presenting malunited intra-articular fractures of the base of the middle phalanx. J Hand Surg [Am]. 2005. 30(5):e1-1039.e14.

Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res. Apr 2006. 445:133-145.

Orbay JL, Touhami A. The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails. Hand Clin. Aug 2006. 22(3):279-86.

Pehlivan O, Kiral A, Solakoglu C, Akmaz I, Kaplan H. Tension band wiring of unstable transverse fractures of the proximal and middle phalanges of the hand. J Hand Surg [Br]. Apr 2004. 29(2):130-134.

Roth JJ, Auerbach DM. Fixation of hand fractures with bicortical screws. J Hand Surg [Am]. Jan 2005. 30(1):151-3.

van Oosterom FJ, Ettema AM, Mulder PG, Hovius SE. Impairment and disability after severe hand injuries with multiple phalangeal fractures. J Hand Surg [Am]. Jan 2007. 32(1):91-5.

Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg [Am]. Sep 2003. 28(5):856-65.

Brian J Divelbiss, MD Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City

Brian J Divelbiss, MD is a member of the following medical societies: Alpha Omega Alpha, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Mark E Baratz, MD Orthopedic Specialists of UPMC

Mark E Baratz, MD is a member of the following medical societies: Allegheny County Medical Society, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand, Orthopaedic Research Society, Pennsylvania Orthopaedic Society

Disclosure: Received royalty from Integra Life Sciences; Received consulting fee from Integra Life Sciences for speaking and teaching; Received grant/research funds from Integra Life Sciences; Received consulting fee from Elizur for consulting.

Sameer Jain, MD Resident Physician, Department of Orthopaedic Surgery, Allegheny General Hospital

Sameer Jain, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

Milton B Armstrong, MD, FACS Associate Professor of Clinical Surgery, Associate Professor of Clinical Orthopedics, Department of Surgery, University of Miami, Leonard M Miller School of Medicine

Milton B Armstrong, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, and National Medical Association

Disclosure: Nothing to disclose.

Plastic Surgery for Phalangeal Fracture and Dislocation

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