FINGER PROXIMAL PHALANX FRACTURE ADULT

Fracture Nomenclature for Finger Proximal Phalanx Fracture Adult

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Finger Proximal Phalanx Fracture Adult, the historical and specifically named fractures include:

Proximal Phalanx Base Volar Plate Avulsion Fracture with Complete or Partial MP Joint Dislocation

Proximal Phalanx Base MP Joint Collateral Ligament Avulsion Fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

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Proximal phalanx fractures are some of the most common fractures in the body, occurring more frequently than those of the middle phalanx but less frequently than those of the distal phalanx. They often present with apex volar angulation due to the insertion of the interosseus muscle onto the proximal phalanx base, which flexes its proximal fragment while the distal fragment is hyperextended by the central slip acting on the base of the middle phalanx. These injuries can also be significantly disabling and are very difficult to treat due the presence of important joints on both ends of the bone.^1-4

Definitions

• A proximal phalanx fracture is a disruption of the mechanical integrity of the proximal phalanx.
• A proximal phalanx fracture produces a discontinuity in the proximal phalanx contours that can be complete or incomplete.
• A proximal phalanx fracture is caused by a direct force that exceeds the breaking point of the bone.

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Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

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S - Stability (stable or unstable)

• Universally accepted definitions of clinical fracture stability is not well defined in the hand surgery literature. ^5-7
• Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained with simple splinting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
• Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable proximal phalanx fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern

• Proximal phalanx head: oblique, transverse, or comminuted; can involve the proximal interphalangeal (PIP) joint; these are intra-articular fractures that affect one or both condyles of the proximal phalanx head, with or without displacement; displaced fractures can affect joint congruity.
• Proximal phalanx shaft: transverse, oblique, or comminuted with or without shortening
• Proximal phalanx base: can involve the metacarpophalangeal (MCP) joint; fractures of the lateral volar base of the proximal phalanx are common and usually represent collateral ligament avulsion injuries, while comminuted fractures involving the articular surface of the base of the proximal phalanx are relatively rare.⁸
• Overall, spiral and oblique fractures are most common in the proximal phalanx.⁹

O - Open

• Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the proximal phalanx require antibiotics with surgical irrigation and wound debridement.^5,10,11

R - Rotation

• Proximal phalanx fracture deformity can be caused by rotation of the distal fragment on the proximal fragment. Significant malrotation can affect the position of fingertip during grip.
• Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.
• Oblique fractures often produce rotational deformities, but they may also angulate or shorten.⁹

A - Angulation (fracture fragments in relationship to one another)

• Angulation is measured in degrees after identifying the direction of the apex of the angulation.
• Straight: no angulatory deformity
• Angulated: bent at the fracture site
• Example: displaced fractures at the base of the proximal phalanx often exhibit apex volar angulation due to the pull of extrinsic and intrinsic muscles originating in the forearm and hand, respectively.^11,12

D - Displacement (Contour)

• Displaced: disrupted cortical contours (eg, bicondylar fractures of the proximal phalanx head are nearly always displaced and often comminuted).⁹
• Nondisplaced: fracture line(s) defining one or several fracture fragment fragments; however, the external cortical contours are not significantly disrupted

I - Intra-articular involvement

• Fractures that enter a joint with one or more of their fracture lines.
• Proximal phalanx fractures can have fragment involvement with the PIP or MCP joints.
• If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.
• Fractures of the distal third of the proximal phalanx are often intra-articular and benefit from closed reduction and percutaneous pinning to minimize dissection around the PIP joint.¹³

C - Closed

• Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.^5-7

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Proximal phalanx fractures: named fractures, fractures with eponyms and other special fractures

Proximal Phalanx Base Volar Plate Avulsion Fracture with Complete or Partial MP Joint Dislocation

• Traumatic dislocation of the MCP joint is regarded as a rare injury, but some evidence suggests that this is due to significant underreporting.¹⁴
• The capsule of the MCP joint extends from the metacarpal neck to the base of the proximal phalanx and is reinforced by ligamentous structures on all sides. The proper collateral ligaments are the primary stabilizers of the MCP joint throughout its range of motion (ROM). The volar plate stabilizes and supports the MCP joint on the palmar aspect.
  • The MCP joint is weakest dorsally, as the dorsal capsule is thin and loose, with the extrinsic extensor tendons located directly dorsal to this capsule.¹⁴
• The usual mechanism of injury to an MCP joint is a fall on the outstretched hand (FOOSH), causing forcible hyperextension of the joint. Dorsal dislocations are more frequent than volar dislocations, and MCP joint dislocations are less common than IP dislocations. The index finger is most frequently involved, followed by the thumb.¹⁴
• When the MCP joint dislocates, the proximal phalanx typically moves dorsal to the metacarpal head, which can cause an avulsion fracture of the volar plate into the joint. When the interposed volar plate prevents closed reduction, the MCP dislocation is considered complex. In addition, the metacarpal head may be entrapped in the tendons and ligamentous structures as it displaces volarly.^15,16
• Concomitant fractures of the base of the proximal phalanx and metacarpal head occur in about 50% of MCP joint dislocations.¹⁴

Imaging

• AP, lateral, and oblique X-ray views are needed to confirm the diagnosis. Lateral is the most useful view.

Treatment

• Some simple dislocations can be reduced non-surgically with initial MCP hyperextension followed by dorsal pressure on the proximal phalanx in conjunction with wrist flexion.
  • The MCP should then be splinted for 3-4 weeks to prevent hyperextension with a hand-based MCP joint splint.¹⁴
• Complex MCP dislocations typically require open surgical reduction.¹⁶
  • Simple distraction as a reduction maneuver is usually unsuccessful and can inadvertently convert a reducible dislocation into an irreducible one, as traction on the MCP joint can draw the entire volar plate dorsally so that it can be completely folded between the base of the proximal phalanx and metacarpal head.¹⁴
  • Both volar and dorsal surgical approaches to MCP joint reduction have been described and utilized, with both being associated with unique advantages over the other.^14,16

Complications

• Posttraumatic osteoarthritis
• Osteonecrosis
• Stiffness
• Decreased ROM

Outcomes

• Universal consensus has not yet been reached on whether a volar or dorsal surgical approach to MCP reduction is superior.¹⁶
• One study found that complex MCP joint dislocations treated on the day of injury with either a dorsal or volar approach led to good results with minimal arthritis and no functional deficits or pain.¹⁵
• In another study in which the surgical approach was determined by the surgeon’s preference, the dorsal approach was found to be faster and less likely to require a second approach to achieve reduction than the volar approach.¹⁶
  • The volar approach may also present additional challenges for a surgeon less familiar with MCP joint anatomy.¹⁶
  • When approaching the MP joint volarly, one may find the neurovascular bundle has been displaced into the superficial subcutaneous tissues.

Proximal Phalanx Base MP Joint Collateral Ligament Avulsion Fracture

• Fractures of the lateral volar base of the proximal phalanx are common, but rarely result in avulsion fractures of the radial or ulnar collateral ligament.^8,9
  • These injuries are thought to occur secondary to the pull of the collateral ligaments during forced abduction or adduction of the finger with the joint flexed.^8,9
• Anatomically, the ligamentous structures of the MCP joint predispose the base of the proximal phalanx to be more vulnerable to avulsion fractures compared to the IP joints; however, PIP fractures are more common.
  • The collateral ligaments of the MCP joint insert entirely on the epiphysis of the proximal phalanx, whereas in the IP joints, the insertion of the collateral ligaments includes the epiphysis and metaphysis.¹⁷

Imaging

• X-ray

Treatment

• Management of avulsion fractures of the base of the proximal phalanx is not as adequately covered in the literature as PIP joint avulsion fractures.¹⁷
• Small avulsion fragments comprising less than 25% of the articular surface can be treated closed, but with an element of shear stress during injury, the fragments are often larger and surgery is needed. Most commonly, a notably sized volar ulnar or volar radial fragment with a central depressed fragment of the articular surface exists.⁸  If there are large fragments that are significantly displaced, malrotated, or intraarticular with a step-off, then surgical treatment is indicated.  Open reduction and internal fixation may also be indicated for a displaced avulsion fracture with gross instability.¹⁸  A volar A1 pulley sparing technique for fixation of MCP joint avulsion fractures is another minimally invasive and direct approach that can be used to internally fix these fractures.^17,18  

Complications

• Flexor tendon adhesion
• Bowstring of flexor tendons
• Plate prominence
• Stiffness
• Post-traumatic arthritis

Outcomes

• Several studies have yielded positive outcomes in patients treated with the A1 pulley sparing technique for fixation of MCP joint avulsion fractures.^8,17,18
  • In one study, all fractures treated with this technique healed uneventfully and anatomical reductions were regained. All patients also regained finger joint ROM and none presented with MCP joint instability. This technique allowed the fracture fragments to be reduced and fixed from the volar aspect of the finger with less risk of damage to the flexor tendon or MCP joint.¹⁸
  • Another study reported satisfactory results in which all patients revealed full- or almost-full ROM of the MCP joint without evidence of lateral instability, grip strength of at least 90% of the uninjured hand, and no flexor tendon disturbance.¹⁷

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Related Anatomy

• The proximal phalanx consists of a distal phalangeal head that articulates at the PIP with the middle phalanx, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the MCP joint with the metacarpal.
• The ligaments associated with the proximal phalanx at the PIP and MCP joints are the joint capsule, the collateral ligaments (proper and accessory collateral), and the volar and palmar plates. The transverse and oblique bands of the retinacular ligament are also associated with the proximal phalanx. The oblique band originates on the lateral volar aspect of the proximal phalanx and attaches dorsally to the common extensor, while the transverse band originates and attaches closer to the joint line and inserts on the lateral border of the proximal phalanx.
• Tendon attachments include the sagittal bands of the extensor digitorum tendon and a flexor sheath that attaches to the sides of the proximal phalanx.
• There is a basic anatomical difference between the proximal and middle phalanges: the proximal phalanges have a longer, wider intramedullary canal with more cancellous bone, whereas the middle phalanges have a shorter, narrower intramedullary canal with more cortical bone.¹⁹ In general, fractures through cortical bone heal slower than fractures in cancellous bone.

Incidence and Related injuries/conditions

• Metacarpal and phalangeal fractures account for nearly half of all hand injuries that present to the emergency room.²⁰
• Fractures of the proximal phalanx rank behind the distal phalanx and ahead of the middle phalanx in terms of prevalence, with on study reporting that proximal phalanx fractures account for about 13% of all hand fractures.³
• While transverse fractures tend to be more common in the middle phalanx, spiral and oblique fractures of the shaft are more common in the proximal phalanx.⁹
• Phalangeal fractures account for 23% of all below-elbow fractures.²¹

A classic patient with a proximal phalanx fracture is a 33-year-old, right-handed male construction worker, who was sawing a piece of wood when an unsecured 2X4 fell over and landed on the outside of his right hand. The impact caused in an oblique fracture of the proximal phalanx shaft of his right little finger, and led to severe pain, swelling, and immediate temporary loss of range of motion.

• Finger stiffness is the most common complication of hand fractures,^5,11 but proximal phalanx fractures can usually be immobilized rapidly enough to avoid this. Stiffness is also far more difficult to treat than malunion, nonunion, and arthrosis combined.¹¹
  • Unstable proximal phalanx fractures, especially in older patients and in the setting of digital arthritis, are likely to result in stiffness if treated conservatively.¹¹
  • Surgery of proximal phalanx fractures and long postoperative protection are also risk factors for postoperative stiffness due to surgery-induced adhesions with extensor tendons or joint contracture. Stiffness, swelling, and contractures are even possible in surgical fixation cases in which union is achieved with excellent anatomic alignment.^1,4
• Malunion and fingertip deformity after proximal phalanx fractures are rare but can occur, especially in open, severe, unstable fractures.²³ Malunions with malrotation can also occur.
• Posttraumatic osteoarthritis can occur in the MCP joint after some proximal phalanx fractures with volar plate avulsion fractures or large collateral ligament avulsion fractures.
• Chronic osteomyelitis of the proximal phalanx is rare but can occur in open fractures, especially in diabetic patients or those with a compromised immune system.
  • Established phalangeal osteomyelitis is extremely difficult to eradicate, and even after surgery, the final result is often a painful, stiff, useless digit. Amputation may therefore be considered under such circumstances.⁹
• Other possible complications of proximal phalanx fractures include infection, apex volar angulation, lateral angulation, nonunion or delayed union, loss of motion, and flexor tendon rupture or entrapment.⁹

• Most outcomes for phalanx fractures are very good,^5,11,24 however, the prognosis is generally worse for fractures of the proximal phalanx than for the middle or distal phalanx, as any proximal phalanx fracture could potentially compromise the hand’s overall function.⁴  Fortunately, the complications noted above are very rare. Significant stiffness can usually be avoided because distal interphalangeal (DIP) and PIP joints of the injured finger can be mobilized while the MCP joint and proximal phalanx are splinted.
• In one study, unstable extra-articular proximal phalanx fractures were treated with rigid ORIF followed by early mobilization and rehabilitation with protective splints during the first 3-4 postoperative weeks. This treatment approach led to 86.3% of patients having excellent results with high patient satisfaction.¹
• One study found that extra-articular fractures of the proximal phalanx—including complex and oblique fractures—could be treated conservatively with flexion splinting at the MCP joint and early ROM exercises, as patients were found to have acceptable outcomes and few complications.²
• Another study found that a variety of surgical interventions for closed, isolated proximal phalanx fractures led to good functional outcomes of the hand including a satisfactory recovery of finger ROM.
  • Functional outcomes were finger-dependent: excellent for the index finger, very good for the little finger, good for the middle finger, and poor for the ring finger.
  • Flexion and strength recovery were better for extra-articular fractures.
  • Better PIP ROM was reported for screw, plate, and pin fixation, in that order.
  • Better strength recovery was reported when rehabilitation was started immediately after the surgical procedure.
  • The most common complications were stiffness, slight discomfort due to malrotation, and cold intolerance.
  • Complete union was observed for all fractures at the post-operative radiological assessment.²
• Another study found that K-wire fixation is a reliable and technically simple method for treating unstable proximal fractures that results in good or excellent long-term results and low complication rates in appropriately selected patients. Researchers also observed that cast splinting provided adequate treatment for stable proximal phalanx fractures in this study group.²⁵

• Finger fractures must be immobilized before radiographic fracture healing is complete to avoid disabling finger stiffness.
• Immobilization of finger fractures for >4 weeks is rarely needed.  Typically, fractures that are treated closed can begin mobilization at three weeks and fractures that require open reduction and internal fixation can be mobilized at four weeks.⁹
• Today, as in ancient times, finger fractures can usually be treated without surgery.^7,9
• Underlying pathological conditions such as bone tumors—like enchodromas—and osteoporosis should be expected in fractures that occur from trivial trauma.  Usually these pathological fractures can be allowed to heal before treating the enchondroma.
• The functional needs of each patient must be considered when recommending treatment for proximal phalanx fractures.
• Anatomical fixation of proximal phalanx fractures with screws—with or without plates—is fraught with problems, as the intra- and postoperative disturbance of the closely aligned extensor tendon mechanism often leads to stiffness.¹¹
• Surgical management of proximal phalanx fractures can lead to poor functional outcomes if the appropriate surgical method is not utilized.⁴
• Fractures of the proximal phalanx are difficult to treat due to the presence of an important joint on either end of the bone.³

New and Cited Articles

1. Ataker Y, Uludag S, Ece SC, Gudemez E. Early active motion after rigid internal fixation of unstable extra-articular fractures of the proximal phalanx. J Hand Surg Eur Vol 2017;42(8):803-809. PMID: 28589776
2. Held M, Jordaan P, Laubscher M, et al. Conservative treatment of fractures of the proximal phalanx: an option even for unstable fracture patterns. Hand Surg 2013;18(2):229-34. PMID: 24164128
3. Jehan S, Chandraprakasam T, Thambiraj S. Management of proximal phalangeal fractures of the hand using finger nail traction and a digital splint: a prospective study of 43 cases. Clin Orthop Surg. 2012;4(2):156-62. PMID: 22662302
4. Desaldeleer-Le Sant AS, Le Sant A, Beauthier-Landauer V, et al. Surgical management of closed, isolated proximal phalanx fractures in the long fingers: Functional outcomes and complications of 87 fractures. Hand Surg Rehabil 2017;36(2):127-135. PMID: 28325427
5. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
6. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
7. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
8. Hattori Y, Doi K, Sakamoto S, et al. Volar plating for intra-articular fracture of the base of the proximal phalanx. J Hand Surg Am 2007;32(8):1299-303. PMID: 17923319
9. Day CS. Fractures of the Metacarpals and Phalanges. In: Green DP, ed. Green's Operative Hand Surgery. Seventh ed. Philadelphia: Elsevier:231-77.
10. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12:119-26. PMID: 28344521
11. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
12. Chen F, Kalainov DM. Phalanx fractures and dislocations in athletes. Curr Rev Musculoskelet Med 2017;10(1):10-16. PMID: 28185123
13. Lögters TT, Lee HH, Gehrmann S, et al. Proximal Phalanx Fracture Management. Hand (N Y) 2017:1558944717735947. [Epub] PMID: 29078727
14. Dinh P, Franklin A, Hutchinson B, et al. Metacarpophalangeal joint dislocation. J Am Acad Orthop Surg 2009;17(5):318-24. PMID: 19411643
15. Rubin G, Orbach H, Rinott M, Rozen N. Complex Dorsal Metacarpophalangeal Dislocation: Long-Term Follow-Up. J Hand Surg Am 2016;41(8):e229-33. PMID: 27311864
16. Vadala CJ, Ward CM. Dorsal Approach Decreases Operative Time for Complex Metacarpophalangeal Dislocations. J Hand Surg Am 2016;41(9):e259-62. PMID: 27406323
17. Kuhn KM, Dao KD, Shin AY. Volar A1 pulley approach for fixation of avulsion fractures of the base of the proximal phalanx. J Hand Surg Am 2001;26(4):762-71. PMID: 11466655
18. Kaneshiro Y, Hidaka N. Volar A1 pulley sparing technique for fixation of avulsion fractures of the base of the proximal phalanx. J Plast Surg Hand Surg 2014;48(1):56-8. PMID: 23731133
19. Dhamangaonkar AC, Patankar HS. Antegrade joint-sparing intramedullary wiring for middle phalanx shaft fractures. J Hand Surg Am 2014;39(8):1517-23. PMID: 24855966
20. Mansha M, Miranda S. Early results of a simple distraction dynamic external fixator in management of comminuted intra-articular fractures of base of middle phalanx. J Hand Microsurg 2013;5(2):63-7. PMID: 24426677
21. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908-15. PMID: 11561245
22. Singh J, Jain K, Mruthyunjaya, Ravishankar R. Outcome of closed proximal phalangeal fractures of the hand. Indian J Orthop 2011;45(5):432-8. PMID: 21886925
23. Kaplan SJ. Bony complications caused by stack splints. J Hand Surg Am 2013;38:2305-6. PMID: 24207001
24. Yoon JO, Baek H, Kim JK. The Outcomes of Extension Block Pinning and Nonsurgical Management for Mallet Fracture. J Hand Surg Am 2017;42:387 e1- e7. PMID: 28274605
25. Ozçelik D, Toplu G, Unveren T, et al. Long-term objective results of proximal phalanx fracture treatment. Ulus Travma Acil Cerrahi Derg 2011;17(3):253-60. PMID: 21935805
26. Shah CM, Sommerkamp TG. Fracture dislocation of the finger joints. J Hand Surg Am 2014;39:792-802. PMID: 24679912

Reviews

1. Lögters TT, Lee HH, Gehrmann S, et al. Proximal Phalanx Fracture Management. Hand (N Y) 2017:1558944717735947. [Epub] PMID: 29078727
2. Dinh P, Franklin A, Hutchinson B, et al. Metacarpophalangeal joint dislocation. J Am Acad Orthop Surg 2009;17(5):318-24. PMID: 19411643

Classics

1. Lamphier TA. Improper reduction of fractures of the proximal phalanges of fingers. Am J Surg 1957;94(6):926-30. PMID: 13478816
2. Pratt DR. Exposing fractures of the proximal phalanx of the finger longitudinally through the dorsal extensor apparatus. Clin Orthop 1959;15:22-6. PMID: 14434678