PHALANGEAL FRACTURES

Jarosaw Czubak Department of Orthopaedics, Pediatric Orthopaedics and Traumatology Postgraduate Medical Education Center Warsaw, Poland

DISTAL PHALANX FRACTURE

Case 1 History of Present Illness(HPI) A 14-year-old boy presents to ER with pain,

swelling, and limited motion in the right distal phalanx of the index finger. Two hours ago he was playing football with his team. During the match he was trying to take over the ball, he accidentaly grabbed the collar of the T-shirt of the other boy playing on the opposite team. He pulled it hard enough to hear the snap and feel the pain in his index finger.

The mechanism of injury Jersey finger

Forced extension of the flexed DIP joint

Case 1 Pysical examination

On physical examination theres a swelling in the area of middle and distal phalanx. There is a subungual hematoma that involves 60% of the nail plate, but no nail bed laceraion.

No other damage to soft tissue is visible. Patient is not able to actively flex the DIP

joint.

Caise 1 X-ray examination

What is the structure at risk in tis patient?

A flexor digitorum profundus avulsion fracture of the distal phalanx Jersey finger

Is it physieal or extraphysieal fracture? How would you treat this patient?

Classification of distal phalanx fractures Extraphyseal - Transverse diaphysis - Longitudinal splitting - Comminuted

separations - Avulsion of flexor with

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Classification of distal phalanx fractures

Physeal - Salter-Harris I or II - Salter-Harris III or IV - Salter-Harris I or II

joint dislocation - Avulsion of extensor

with Salter-Harris fracture

Extraphyseal fractures treatment

Simple closed fractures immobilization 3-4 weeks

Unstable fractures percutaneous pinning with Kirschner wire

(DIP joint usually is transfixed)

Distal phalanx fracture operative management

Extremely unstable extraphyseal fractures with wide displacement stabilization with K wires

Physeal fracture with a

dorsal fragment larger than 50% of the epiphysis require operative intervention

Distal phalanx fracture operative management

Open unstable injuries with severe displacement or

irreducible fractures require stabilization

Avulsion of the flexor digitorum profundus open

reduction

Physeal fractures treatment options

Reduction and splinting Surgery is indicated for: - open fractures - gross unstable fractures - irreducible fractures - unacceptable alignment

Case 1 Treatment Remember to evacuate the subungual

hematoma!

The stability of phalangeal fracture was evaluated and since the phalanx was not stable enough to act as foundation for nail bed repair, pinning was performed.

The patient was scheduled for follow up in 2 weeks.

The results were satisfactory.

Early diagnosis of fractures of phalanges

is very important. Undiagnosed fractures can cause

prolonged pain, pseudoarthrosis and problems in therapy.

Mallet finger

Mechanism of injury- hyperflexion force

PROXIMAL AND MIDDLE PHALANX FRACTURE

NOTE! The detailed information on this subject is available in your handouts!

Case 2 History of Present Illness

13-year-old female pateint presents to your office with pain, swelling and red dots in her right thumb. The pain started 2 days ago when she was skiing. She doesnt remember the exact time when the pain started.

Mechanism of injury-forced hyperextension of the thumb

Case 2 Physical examination On physical examination the right thumb is

swollen, particularly in the area of MCP joint.

The ecchymosis extends out into the skin of the first web.

On palpation ulnar side of the thumb is sensitive to touch

The range of motion is decreased due to pain especially during flexion and extension.

What would you do next?

Case 2 X-ray Because the routine X-ray showed no bone

injury the stress X-ray was performed applying lateral force with the joint in full extension first, then in full flexion.

NOTE! The median and superficial radial nerves were bloked of with lidocaine in order to perform this examination.

Case 2 X-ray

On stress examination, a widening of the physis is seen. No true intraarticular fracture can be appreciated.

What is your diagnosis?

A stress examination

NOTE! A stress examination should not be performed

until a bony injury is rulled out! If no fracture is present , the proxiaml phalanx is

stressed radially with the MCP joint fully flexed and fully exended. Inability o full extension can be present only if the UCL and volar plate are completely ruptured. Otherwise, the degree of opening in flexion helps differentiate partial (30 degrees) injuries of the UCL.

Ulnar instability of the thumb MCP joint

A. Simple sprain B. Rupture of the ligament C. Avulsion fracture SH type III D. Pseudo-gamekeepers

injury resulting from a SH type I or II fracture of the proximal phalanx

Skiers or Gamekeepers thumb

ulnar collateral ligament nearly always separates from the base of first phalanx of the thumb

it frequently becomes lodged between

adductor pollicis aponeurosis and its normal position (Stener Lesion)

Ulnar collateral ligament Adductor pollicis

Stener lesion occurs when the proximal portion of the torn proper ligament of the ulnar side of the thumb MCP joint comes to lie dorsal to the leading edge of the adductor aponeurosis.

Treatment

Slightly displaced Gamekeeper's fractures tend to do well with immobilization

In case of Stener leasion surgical intervention is mandatory in order to repair the ligament

A dispalced avulsion fracture of the base of the proximal phalanx may occasionaly require ORIF with a single screw if the fragment is large enough.

Chronic UCL injuries require ligament reconstruction with the use of adjacent joint capsule or a tendon graft.

Case 2 Treatment Since the patient was diagnosed with partial

injury (stress X-ray results and physical examination findings) we decided to treat her with thumb spica cast immobilization for 4-6 weeks.

The follow-up was scheduled in 4 weeks.

Thank you very much!

PHALangeal fracturesdistal phalanx fractureCase 1History of Present Illness(HPI)The mechanism of injury Jersey fingerCase 1 Pysical examinationCaise 1 X-ray examinationA flexor digitorum profundusavulsion fracture of the distal phalanxJersey fingerClassification of distal phalanx fracturesClassification of distal phalanx fracturesExtraphyseal fractures treatmentDistal phalanx fracture operative managementDistal phalanx fracture operative managementPhyseal fractures treatment optionsCase 1TreatmentFoliennummer 15Mallet fingerProximal and middle phalanx fractureCase 2History of Present IllnessMechanism of injury-forced hyperextension of the thumbCase 2Physical examinationCase 2X-rayCase 2X-rayA stress examinationUlnar instability of the thumb MCP jointSkiers or Gamekeepers thumbStener lesion occurs when the proximal portion of the torn proper ligament of the ulnar side of the thumb MCP joint comes to lie dorsal to the leading edge of the adductor aponeurosis.TreatmentCase 2TreatmentFoliennummer 29