Proximal Phalanx #’s
These are more common than middle phalangeal fractures. Malunion, shortening, and tendon adherence is more problematic here than distally. Unstable fractures usually present with a recurvatum, apex volar, dorsally angulated deformity because of the flexion influence of the interossei, and the extension moment of the central slip on the middle phalanx. There is almost no area of the proximal phalanx where the risk of tendon adhesions following fractures is not high.
Numerous Methods of Treatment
Buddy Taping (no reduction, early motion)
– simply tape the injured finger to an adjacent normal digit and encourage motion
– the fracture must be STABLE – undisplaced, or impacted with NO angulation
Closed Reduction and Immobilization
– the closed reduction must be performed before splinting and must be STABLE – the splint merely holds the reduction.
– transverse fractures generally fall into this category; spiral fractures are often not stable enough to be maintained by a splint after the initial reduction.
– immobilization should be in full MP flexion, and PIP/DIP extension (intrinsic plus); PIP joints become more stiff in flexion, but the reason for this is obscure.
Closed Reduction and K-wires
– often gives sufficient stability, without added surgical trauma of open reduction.
– good for transverse fractures, spiral oblique fractures are often difficult but can be done
– numerous methods of fixing proximal phalanx – through metacarpal head, across joint, into condyle
– if position of wires is good and stability is sufficient, early motion can be instituted
Open Reduction, Internal Fixation
– most intra-articular fractures involving the PIP joint
– often done with K-wires; Steinmann pin intramedullary fixation, tension band wiring, cerclage wiring, plates are also described
– must ask yourself whether the added surgical trauma is worth it.
Guidelines for Treatment
It is not clear what constitutes acceptable alignment. From Jupiterï¿½s book, it is suggested that dorsal angulation of more than 20o in the adult and 30o in the child results in impaired function and should be fixed. Medial/lateral deviation more than a few degrees is unacceptable, and rotational deformity should be corrected if clinically apparent. Usually, a rotational malalignment of 10o or less is well tolerated.
Transverse Base and Diaphyseal Fractures
– usually present with apex volar angulation
– if stable and undisplaced, treat with immobilization of the MCP in flexion, with active PIP motion
– if unstable, treat with CRIF with K-wires passed through the metacarpal head and into the proximal phalanx with the MCP in 90o flexion.
Spiral Oblique Fractures
– inherently unstable – they shorten and rotate
– usually require internal fixation with K-wires (either closed or open)
Transverse Neck Fractures
– often presents with the distal fragment extended 60-90o. Reduction is easy to obtain but hard
to maintain with immobilization.
– usually require internal fixation with K-wires, either through the bone or across the PIP
– these almost always collapse, so internal fixation is almost always necessary, often after a dorsal open reduction to visualize the joint surface.
Spiral/oblique fractures behave according to fracture length. Short obliques behave like transverse fractures, while long obliques and spirals are more prone to shortening and malrotation, and therefore may require maintenance of reduction by two parallel K-wires.