Finger (phalanx) fracture

Pearls

• Be wary of avulsion fx of base of phalanx
  • Lateral or medial fracture fragment = collateral ligament avulsion
  • Dorsal fracture fragment = extensor tendon avulsion
  • Palmar fracture fragment = volar plate avulsion
• Flexion deformity of distal phalanx (mallet/baseball finger) = avulsion fx or extensor tendon rupture

Proximal Phalanx Fx

• Examination
  • Examine the phalanx with the fingers in full extension and flexion
  • Assess for malrotation
• Imaging
  • AP, lateral, oblique
    • Examine for rotation, shortening, angulation
• Treatment
  • If requires ortho referral: Radial or ulnar gutter splint
  • Nondisplaced, stable: Consider buddy taping the injured finger to an adjacent finger
    • If the ring finger is involved it should be buddy taped to the little finger
  • Displaced or angulated fx
    • Consider closed reduction
      • After reduction ensure that PIP joint is in extension, MCP is in flexion (to avoid contracture)
• Disposition
  • Refer for:
    • Intraarticular
    • Unstable
      • Spiral or oblique fx
      • Condylar fx
      • Neck fx
      • Large avulsion fx
    • Rotated
      • NO degree of rotation is acceptable following a reduction
    • Shortened
    • Significantly angulated
      • Less than 10 degrees may be tolerated

Middle Phalanx Fx

• Commonly associated with tendon injuries!
• Examination
  • Assess PIP, DIP flexion/extension
  • Assess PIP, DIP collateral ligaments (varus/valgus stress)
• Images
  • AP, lateral, oblique
  • Oblique and spiral fractures: evaluate for shortening/malrotation
• Treatment
  • Nondisplaced without angulation:
    • Buddy tape to adjacent finger
      • Buddy tape ring finger to little finger
    • Dorsal or volar finger splint if desire added protection
  • Displaced or angulated fx
    • Closed reduction
      • Adequate reduction:
        • <1-2mm displacement or shortening
        • Up to 10 degrees of angulation
        • No amount rotation
      • Followed by ulnar or radial gutter splint
        • Wrist in 20-30 degrees of extension
        • MCP joints in 70-90 degrees of flexion
        • PIP and DIP joints flexed 5-10 degrees
          • Decreases the force exerted by the FDS
• Dispo
  • Refer for:
    • Comminution
    • Malrotation
    • Intraarticular fx
    • Displaced or angulated fractures that cannot maintain their reduction
    • Most spiral and oblique fx (usually involve rotation or shortening and are unstable)

Distal Phalanx Fx

• Examination
  • Evaluate for tendon damage
• Imaging
  • Comminuted tuft fx
    • Stable
  • Longitudinal fx
    • Usually non-displaced and stable
  • Transverse fx
    • Evaluate for angulation/displacement
  • Intraarticular fx
• Treatment
  • Nondisplaced: Splint with the DIP joint in extension (splint should extend past the tip of the distal phalanx
    • Do not attempt to reduce comminuted tuft fx
• Dispo
  • Refer for:
    • Tendon dysfunction
    • Nerve dysfunction
    • Displacement or angulation
    • Intraarticular fx

Source

UpToDate