Treatment of Phalangeal

F r a c t u re s
Shannon Carpenter, MD, Rachel S. Rohde, MD*

KEYWORDS
 Phalanx  Phalangeal fracture  Treatment  Hand fracture

KEY POINTS
 Fractures involving the tubular bones of the hand are the most common skeletal injuries.
 The primary goals of phalangeal fracture treatment are to restore anatomy and preserve function.
Lost productivity attributed to these fractures exceeds $2 billion every year, making early return to
activities a key goal as well.
 The preferred method of treatment is one that offers limited soft tissue damage and enables mobi-
lization of the injured digit(s) as soon as fracture stability permits.
 Technical treatment of phalangeal fractures depends on characteristics of the fracture, require-
ments of the patient, and judgment of the treating physician. In general, operative treatment is
reserved for unstable fractures or those creating unacceptable articular incongruity.
 Optimal outcome from surgical treatment demands appropriate surgical plan, atraumatic soft
tissue handling, and stable fixation to facilitate early motion; however, complications such as
nonunion, malunion, infection, and stiffness can occur even in the setting of appropriate treatment.

INTRODUCTION exceeds $2 billion per year,6 a third goal is to mini-

mize recovery time and expedite return to activity.
Philosophies regarding phalangeal fracture treat- The preferred treatment restores anatomy, mini-
ment have evolved over time. The principle of mizes soft tissue injury, and enables mobilization
complete immobilization espoused by Sir Regi- of the injured digit as soon as fracture stability
nald Watson-Jones in 1943 remained uniformly permits.
accepted for many years.1 It was not until 1962
that James proposed what is now known as the
TREATMENT CONSIDERATIONS
“safe position” for immobilization,2 also posing
the question of whether complete immobilization Thorough clinical evaluation is required to determine
of every hand fracture was necessary.3,4 the appropriate treatment course for each patient.
Contemporaneously, Swanson5 asserted that The patient’s age, hand dominance, occupation,
fractures of the hand can be complicated by defor- avocations, medical comorbidities (including to-
mity from no treatment, stiffness from overtreat- bacco use), goals, limitations, and tolerances are
ment, and both deformity and stiffness from poor important factors for the treating physician to
treatment. Ultimately, the primary objectives of consider. The mechanism of injury and associated
phalangeal fracture treatment are to restore anat- injuries also may dictate course of treatment.
omy and preserve function. Given that the lost pro- A careful examination, including clinical and radio-
ductivity associated with phalangeal fractures graphic evaluation is needed, and sometimes is

The authors have nothing to disclose with relation to this publication.

hand.theclinics.com

Department of Orthopaedic Surgery, Oakland University William Beaumont School of Medicine, Beaumont
Health System, 3535 West Thirteen Mile Road #742, Royal Oak, MI 48073, USA
* Corresponding author. Michigan Orthopaedic Institute, P.C., 26025 Lahser Road, Second Floor, Southfield,
MI 48033.
E-mail address: [email protected]

Hand Clin 29 (2013) 519–534

http://dx.doi.org/10.1016/j.hcl.2013.08.006
0749-0712/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
520 Carpenter & Rohde

supplemented with advanced medical imaging (eg,

computed tomography).7,8
Acceptable alignment limitations vary based on
the anatomic location of the fracture as well as
the age of the patient, which suggests remodel-
ing potential. However, one of the key general
determinants of whether a fracture will require
operative treatment is its inherent stability
(Table 1).9

TREATMENT OPTIONS
A phalanx fracture can be addressed using one (or
more) of several treatments based on clinical and
radiographic assessment of the fracture and any
associated injuries.

Nonoperative Treatment
A vast majority of phalangeal fractures can be
managed nonoperatively.10–13 These include frac-
tures that are incomplete, nondisplaced, or able to
be reduced so that acceptable alignment and sta-
bility are maintained without operative fixation.
Nonoperative treatments include the following:
Fig. 1. Unless there is a specific rationale, casting of
 Closed reduction (if needed) and casting or the digits should be performed in intrinsic plus posi-
functional bracing (Fig. 1) tion: 70 of flexion at the MCPJs and full extension
 Closed reduction and dorsal block splinting at the IPJs.
(Fig. 2)
 Buddy strapping or taping (Fig. 3) (MPJs) are maintained at 70 of flexion and the
proximal interphalangeal joints (PIPJs) in full
It is important to emphasize that “nonoperative”
treatment is not without its pitfalls, and using the extension (see Fig. 1). Exceptions to this are
made when the position must be altered for
appropriate nonsurgical technique is as critical
as using the appropriate operative one. The
“safe” or “intrinsic plus” position of James3 is
used to prevent collateral ligament and volar plate
contractures. The metacarpophalangeal joints

Table 1
Characteristics predictive of phalangeal
fracture stability

Stable Unstable
Anatomic Distal Subcondylar
location phalanx proximal
phalanx
Fracture Simple, Short oblique,
characteristics transverse spiral
Impacted Comminuted
Displacement None or Displaced,
minimal malrotated
Articular None or Incongruous
incongruity minimal surface Fig. 2. Dorsal block splinting of the PIPJ allows active
flexion exercises while maintaining reduction of
Soft tissue injury Minimal Severe
potentially unstable volar plate avulsion injuries.
 Phalangeal Fractures 521

The authors prefer to consider these as extra-

articular fractures of the tuft, shaft, or base, and
intra-articular fractures.

Distal Phalangeal Tuft Fractures

Tuft fractures usually occur secondary to a crush-
ing injury and are often associated with a lacera-
tion of the nail matrix, pulp, or both. “Closed”
fractures, therefore, result in the formation of a
subungual hematoma, which often is more painful
than the fracture itself. In this case, decompres-
sion of the hematoma using a trephine or electro-
cautery will provide pain relief. This perforation of
the nail bed converts a closed fracture into an
open one and a short course of oral antibiotics
should be considered as a result.14,17–19
Open tuft fractures are less stable than closed
fractures because the supporting pulp and nail
plate are disrupted. Nevertheless, these rarely
require internal fixation. Careful approximation of
the associated lacerations of the pulp and nail ma-
trix (following removal of the nail plate, if neces-
sary) will restore alignment of the associated
bony injury. Replacement of the nail plate or
appropriate substitute beneath the eponychial
fold prevents adherence of the fold to the matrix
and serves as a splint for the fracture (Fig. 4).
Rarely, a 0.028-inch Kirschner wire (K-wire) is
used to support a fracture that remains unstable
Fig. 3. Buddy straps or buddy tape allows the neigh- or displaced despite restoration of the soft tissue
boring digit to act as a splint that provides support envelope.
but allows early motion.
A short (10–14-day) period of immobilization of
the middle and distal phalanges will provide
symptomatic relief and support of the fracture.
treatment purposes (eg, dorsal block splinting of Unrestricted PIPJ movement should be allowed
PIPJ fracture-dislocations). to minimize subsequent motion loss. Radio-
graphic delayed or nonunion frequently occurs,
Operative Treatment but symptom resolution is suggestive of fibrous
union.
Surgical treatment is necessary if the fracture Potential complications following distal
pattern is unstable or if the fracture is intra- phalangeal tuft injuries include persistent pain,
articular and creates an unacceptable articular infection, cold intolerance, altered sensibility,
incongruity (see Table 1).9 Operative options and nail bed and nail deformity, malunion, and
their potential uses are introduced in nonunion.20
Table 2.7,14,15
Distal Phalangeal Shaft Fractures
TREATMENT OF DISTAL PHALANX The distal phalangeal diaphysis generally fractures
FRACTURES either longitudinally or transversely. Because of
Fractures of the distal phalanx constitute almost the inherent stability and minimal displacement
half of all hand fractures.7,9,16 Caused by crushing of these fractures (Fig. 5), most require limited
or axially loading mechanisms, these have been immobilization. Support is maintained until the pa-
classified by the following: tient’s comfort resolves or until radiographic union
is evident.
 Type of fracture (transverse, longitudinal split, Open distal phalangeal shaft fractures are asso-
or comminuted)9 ciated with disruption of the overlying nail matrix.
 Anatomically/soft tissue injury16 As in treatment of an open tuft fracture, the nail
522 Carpenter & Rohde

Table 2
Operative techniques available for treatment of phalangeal fractures

Technique Primary Uses Advantages Disadvantages Complications

K-wires Unstable fractures Minimal effect Need for additional Infection
amenable to on soft tissue immobilization Loosening
closed reduction envelope (cast/brace) Pin migration
Often delays Symptomatic
mobilization hardware
Intraosseous Transverse fractures Possible early Soft tissue irritation Symptomatic
wires or articular mobilization hardware
avulsion fractures
Tension band Avulsion fractures Biomechanically Increased operative Symptomatic
wires stable exposure hardware
Early mobilization Technical difficulty
Compression Large intra-articular Biomechanically Increased operative Fragmentation
screws fragments stable exposure of fracture
Long oblique Early mobilization Technical difficulty intraoperatively
diaphyseal
fractures
Open reduction Complex Most stable Most operative Prominent
internal periarticular or fixation exposure hardware
fixation plate intra-articular Technical difficulty Adhesion
and screws fractures formation
External fixation Open fractures Limits soft Potential Pin site infections
with extensive tissue injury interference Hardware failure
soft tissue injury Preserves length with other digits
Extensive bone loss Nonanatomic
or severe reduction
comminution

should be removed, the fracture reduced, and the (or replaced) nail plate, fractures that remain
nail bed repaired with absorbable suture under unstable can be supported by a 0.028-inch or
loupe magnification. Although most of these frac- 0.035-inch K-wire (Fig. 6). The distal phalanx and
tures are supported adequately by the overlying middle phalanx are splinted for 10 to 14 days.9

Fig. 4. An avulsed or extruded nail plate can be debrided and used as a biologic splint for distal phalanx and nail
bed injuries. (A) The nail plate is prepared for reinsertion. (B) The nail plate is inserted beneath the eponychial
fold and loosely sutured to prevent migration during the early postoperative period.
 Phalangeal Fractures 523

Fig. 6. A small K-wire can be inserted percutaneously

just below the hyponychium if fixation of distal pha-
lanx fragments is needed.

distracted dorsal physis can prevent reduc-

Fig. 5. Alignment of this longitudinal distal phalanx tion.19 High suspicion and immediate recogni-
fracture resulting from crush injury is maintained by tion of this fracture pattern is imperative to
surrounding soft tissues and the nail plate.
prevent recurrent deformity, infection,

Distal Phalangeal Base Fractures

Deforming forces of the flexor and extensor ten-
dons and lack of intrinsic nail plate support render
fractures at the base of the distal phalanx unsta-
ble. Because of these forces, the fracture tends
to angulate with the apex pointing volarly (Fig. 7).

Fractures in the skeletally immature

Although most pediatric fractures are beyond the
scope of this text, 2 distinct physeal injury patterns
occur in children and bear mentioning:
 The Seymour fracture is a complete physeal
separation that occurs from a hyperflexion
injury.21 Typically seen in toddlers, this often
is mistaken for a distal interphalangeal joint
(DIPJ) dislocation or a mallet injury. The
extensor tendon remains attached to the
proximal ephiphyseal fragment while the un-
opposed flexor digitorum profundus (FDP)
tendon pulls the remainder of the distal pha-
lanx into flexion. A transverse laceration of
the nail bed occurs, and the avulsed nail plate Fig. 7. Flexion of the proximal fragment of a distal
lies superficial to the proximal nail fold. Inter- phalangeal base fracture is noted due to the deform-
position of the germinal matrix within the ing force of the FDP tendon.
524 Carpenter & Rohde

residual nail deformity, DIPJ stiffness, and adequate fixation, a transarticular K-wire can be
premature physeal closure.22 used.
 Simple reduction without treatment of the soft
tissue injury can result in loss of reduction and Intra-articular Fractures of the Distal Phalanx
infection. After irrigation and debridement, the
Intra-articular fractures of the distal phalanx most
fracture is reduced using slight traction and
commonly are encountered as avulsion fractures.
manipulation of the distal fragment into exten-
sion. The nail matrix laceration is repaired and  Mallet fractures occur when the dorsal base of
the nail plate replaced beneath the proximal the distal phalanx is avulsed by the attached
nail fold. The use of K-wires should be extensor tendon (Fig. 8). In past years, several
avoided because these are associated with operative techniques have been used to
a higher risk of infection in these injuries.23 restore the articular congruity of these frac-
Although 30 of dorsal or volar angulation tures. However, closed treatment for 6 to
can be tolerated in a young child due to re- 8 weeks in a DIPJ hyperextension splint re-
modeling, it is preferable to attempt to regain sults in excellent outcomes with fewer compli-
anatomic reduction.9 A splint or cast is cations than operative treatment.24,25
applied to hold the distal fragment in exten-  FDP avulsion injuries (Jersey finger) can be
sion for approximately 4 weeks. associated with fracture when the FDP tendon
 Older children incur physeal injuries that avulses a fragment of the volar distal phalanx.
resemble closed mallet injuries; the deformity, This fracture fragment serendipitously can
however, is due to dorsal physeal opening prevent proximal migration of the tendon
rather than extensor tendon disruption. Typi- through the pulley system. Open reduction
cally, closed reduction is easily achieved us- and internal fixation (ORIF) of a large fragment
ing gentle traction and extension of the distal might be considered (Fig. 9). Most fragments,
fragment. Subsequent immobilization in a however, are small, and are inconsequential
splint incorporated into a cast or a cast alone when planning reinsertion of the FDP tendon
should be maintained for 4 weeks.22 into the distal phalanx.

Fractures in adults TREATMENT OF PROXIMAL AND MIDDLE

In adults, a closed fracture at the base of the distal PHALANX FRACTURES
phalanx is best treated by splinting the distal and Treatment decisions regarding proximal and mid-
middle phalanges with the distal interphalangeal dle phalanx fractures merit consideration of the
joint extended for a minimum of 4 weeks. If the following:
fracture is open, it is more likely to be rotationally
unstable and may require K-wire insertion to pro-  Anatomic location within the phalanx (head
vide internal stability. Penetration of the DIPJ usu- [condylar], neck, shaft, base)
ally can be avoided, however, if the proximal  Articular involvement
fragment is too small or too comminuted to allow  Stability of the fracture

Fig. 8. Mallet fractures are treated as

soft tissue injuries. Splinting of the
DIPJ in extension or slight hyperex-
tension allows restoration of DIPJ
extension. These radiographs show
reduction of the fracture fragment
in the splinted position and subse-
quent healing without extensor lag.
Radiographs are not necessary to
confirm healing, which generally is
assessed clinically.
 Phalangeal Fractures 525

 Type II Condylar Fractures

 Unicondylar fractures are inherently unsta-
ble fractures that result from shearing forces
 Closed reduction with or without assistance
of a manipulative K-wire, compression using
a pointed reduction clamp, and percuta-
neous K-wire fixation or percutaneous screw
fixation is preferable if possible to avoid
disruption of the tenuous vascular supply
 Multiple screws or K-wires are necessary to
prevent rotation and loosening
 Superimposition of the condyles on a true
lateral radiograph confirms restoration of
alignment
 ORIF is reserved for displaced fractures not
amenable to closed reduction (see later in
this article)
 Stable fixation allows early motion, and the
PIPJ is splinted in extension, when not in
motion, to prevent extensor lag
 Type III Condylar Fractures
 Bicondylar or comminuted
 Require ORIF, first of the condyles to each
other using K-wires or screw, followed by
fixation of the reassembled head to the
diaphysis
 A minicondylar plate can be used if needed
Fig. 9. Avulsion of a large fragment of the distal pha-  In the case of significant comminution of the
lanx by the FDP tendon (bony Jersey finger) was condyles and/or the adjacent metaphysis,
treated by ORIF of the fragment to its distal phalanx
external fixation can be considered
insertion.
Technical Pearls Specific to Open Treatment of
Inherently stable fractures generally are ame- Phalangeal Condyle Fracture:
nable to nonoperative treatment and protected
early mobilization. Unstable fractures or those  The condyle is approached dorsally by using a
associated with articular incongruity are candi- Chamay approach28 or the interval between
dates for operative intervention. the extensor tendon/central slip and lateral
band
 Before reduction, the condylar fragment di-
Proximal and Middle Phalangeal Condylar
mensions are evaluated to determine appro-
(Intra-Articular) Fractures
priate screw size and the insertion of the
Because of their articular involvement and ten- collateral ligament is identified
dency for rotational displacement, fractures of  The fragment is reduced under direct visu-
the condylar architecture of the phalangeal head alization and fixed provisionally using a
can result in pain, deformity, and loss of motion. 0.028-inch K-wire
Any displacement of a condylar fracture is an indi-  A 1.5-mm headless compression screw is
cation for operative management.14,26,27 Condylar placed just dorsal and proximal to the origin
fractures can be classified into the following 3 cat- of the collateral ligament to preserve the
egories depending on their severity and vascular supply
stability9,15:  A mincondylar blade plate can be used as a
neutralization or buttress plate if there is meta-
 Type I Condylar Fractures physeal or diaphyseal extension of the fracture
 Stable and nondisplaced
 Can be treated nonoperatively in a digital
Proximal and Middle Phalangeal Neck
splint for 7 to 10 days followed by buddy
Fractures
taping and protected mobilization
 Weekly radiographs are useful to monitor These fractures are far more common in children
for displacement than in adults.29 Adult fractures usually are
526 Carpenter & Rohde

amenable to closed reduction and splinting or

crossed K-wire fixation.30,31 Phalangeal neck frac-
tures in children are divided into the following:
 Type I: Nondisplaced fractures are treated
nonoperatively in a splint for 4 weeks. Bony
union and full range of motion without residual
deformity is common.
 Type II: Displaced fractures with persistent
bone-to-bone contact account for about 70%
of these fractures. Treatment and outcome
depend greatly on initial presentation and
management. These fractures are unstable
and maintaining reduction often requires
K-wire fixation. However, the authors note
that these frequently present late (as “finger
jams”) with radiographic evidence of some
healing. It is controversial whether these
should be manipulated or left to remodel at
that point, but the authors observationally
have found that these fractures remodel quite
well in young children (Fig. 10).
 Type III: Completely displaced fractures often
demonstrate rotation of the distal fragment up
to 180 ; these are treated with ORIF using Fig. 11. Incomplete fractures of the phalanx are
K-wire fixation. treated successfully with symptomatic protection,
buddy taping, and early mobilization in an adult (A)
Proximal and Middle Phalangeal Shaft and in a child (B).
Fractures
Nondisplaced fractures of the phalangeal diaph- obliquity (spiral, oblique, or transverse), or unsta-
ysis, particularly those that are incomplete, are ble because of significant bone loss.
stable (Fig. 11).7,10 Fractures that are displaced The initial degree of displacement is more pre-
initially can be classified following closed reduc- dictive of stability than the direction or number of
tion as stable, unstable because of fracture fracture planes.8 Even crush injuries without

Fig. 10. Phalangeal neck fractures often present late, as in the case of this 6-year-old, whose fracture was partially
healed 3 weeks following injury (left). Operative treatment was not chosen because of the likelihood of devas-
cularization of the phalangeal head. Closed treatment in a cast resulted in some remodeling even 3 weeks later
(right).
 Phalangeal Fractures 527

significant displacement are relatively more stable If stable fixation is achieved, digital motion can
than less comminuted fractures if the periosteal be initiated immediately as comfort allows. Protec-
sleeve is maintained.27 In terms of obliquity, a tive splinting is suggested to prevent extensor lag
transverse fracture is inherently more stable than and accidental reinjury.14,33,34
spiral or long oblique fractures, which tend to an-
gulate, rotate, or shorten with the deforming forces Proximal and Middle Phalangeal Base
affecting the phalanx. Fractures
Stable fractures can be treated with buddy tap-
Fractures of the proximal and middle phalangeal
ing and early mobilization. Fractures that are
bases can be either extra-articular or intra-
unstable after reduction or have great potential
articular:
to displace must be treated operatively or at min-
imum followed closely to prevent malunion and  Proximal Phalangeal Base: Intra-articular
subsequent malfunction. result from ligamentous avulsions, crush, or
Unstable transverse fractures can be treated rotation. Operative treatment is considered if
with percutaneous fixation or ORIF with plates the fragment interferes with joint motion or if
and screws. The nature of the phalangeal shaft is joint stability is compromised.35 Most liga-
such that crossed K-wire fixation can be difficult, ment avulsions can be treated successfully
depending on the configuration of the fracture. with buddy taping or functional bracing of
The authors prefer to use a retrograde intramedul- the affected digit to its neighboring digit
lary K-wire for unstable transverse middle phalanx (Fig. 12A). Joint instability at the ulnar aspect
fractures or a transarticular intramedullary K-wire of the thumb metacarpophalangeal joint
across the MPJ for unstable transverse proximal (MCPJ) (“boney gamekeeper”) or the radial
phalanx fractures. This prevents translation, while aspect of the index MCPJ is poorly tolerated
buddy strapping of the digit to its neighbor helps and fixation of the fracture fragment versus
maintain rotational stability.7 debridement and ligament repair should be
Unstable spiral or long oblique fractures can be considered. Intra-articular injuries that involve
stabilized by placing K-wires or compression significant joint incongruity and/or are unsta-
screws across the fracture site (see Technique: ble should be treated operatively (see
Compression Screws). The screw diameter should Fig. 12B).
be less than one-third of the length of the fracture  Proximal Phalangeal Base: Extra-articular are
line, and multiple screws are placed to maintain relatively common.36,37 They result in an apex
stability. Percutaneous screw fixation is an option, volar angulation seen on a lateral radiograph;
but requires perfect closed reduction; if this unfortunately, this might remain unrecognized
cannot be achieved or confirmed, then open following attempted closed reduction
reduction before screw fixation is preferred.15,32 because the fracture site is obscured by

Fig. 12. (A) This intra-articular avulsion fracture at the base of the proximal phalanx was treated by functional
bracing and buddy taping, rendering stability of the joint without pain despite the apparent incongruity. (B)
This intra-articular fracture at the base of the proximal phalanx created significant articular incongruity and is
considered unstable due to obliquity. This was treated with ORIF using compression screw technique.
528 Carpenter & Rohde

plaster or fiberglass. Although stability some-  Complete articular, pilon, impaction, and
times can be achieved following closed lateral plateau fractures can occur at the
reduction, the chance of loss of reduction is base of the middle phalanx. These create
high.38 If acceptable reduction cannot be unacceptable articular congruity and are
maintained, crossed K-wires inserted through treated with ORIF, external fixation, or
the dorsal proximal phalangeal base, crossing reconstruction arthroplasty.15,27,40–47
the fracture site, and purchasing the cortex of
the distal fragment are helpful (Fig. 13). The
Surgical Approaches for ORIF of Proximal and
hand is splinted in the position of function
Middle Phalangeal Fractures
with unobstructed interphalangeal joint (IPJ)
motion until radiographic healing is noted When necessary, open approach to the proximal
(4 to 6 weeks), at which time the K-wires are or middle phalanx can be accomplished via dorsal,
removed and range of motion exercises midaxial, or dorsolateral longitudinal skin inci-
instituted. sions.48 Rarely, a volar approach is necessary to
 Middle Phalangeal Base: Intra-articular address intra-articular fractures at the volar base
 Partial articular of the middle phalanx. Gentle dissection and
- Dorsal: Avulsion fractures of middle pha- thoughtful technique is recommended to minimize
lanx by the central slip (Fig. 14) can be soft tissue disruption. Preserving vascular supply
treated with closed reduction and dy- will promote union, and minimizing tendon manip-
namic extension splinting of the PIPJ. If ulation is thought to decrease adhesion forma-
closed reduction fails, operative fixation tion.34 Stable fixation will allow early mobilization,
of the fracture fragment or tendon rein- which also can help prevent tendon adhesions.49
sertion is considered. Repair of periosteum to protect gliding surfaces
- Volar: Volar plate avulsion fractures and repair of the extensor tendon mechanism
most often involve only a small fragment are critical to ensure a reasonable functional
of the middle phalangeal base avulsed outcome.9
by the detached volar plate. Resulting
from hyperextension injuries or dorsal
Dorsal Approach to the Phalanx
dislocations, nonoperative treatment
consists of buddy taping or, if there is  A midline dorsal incision is made, and the dor-
a potential for redislocation, dorsal sal veins are preserved.50
block splinting. Active range-of-motion  The extensor mechanism is divided longitudi-
exercises are initiated early to minimize nally. Alternatively, in the dorsolateral
stiffness and edema. Instability of the approach, an interval is created between the
joint results when the fracture fragment extensor tendon/central slip and the lateral
involves more than 40% of the articular band. The extensor tendon can be elevated
surface.39 In this case, volar plate ar- and retracted ulnar or radially; this can be
throplasty, ORIF (Fig. 15), or hemiha- facilitated by an incision of the transverse ret-
mate autograft procedures are inacular ligament at the PIPJ.
indicated to restore joint congruity and  PIPJ exposure may require additional
stability. approach:
- Lateral middle phalanx fractures usually  Tendon splitting, in which the central slip
are ligamentous avulsion fractures; un- insertion is reflected but remains attached
less there is unacceptable joint congru- to the periosteum
ity, these are treated with buddy taping  Chamay28 approach, in which the central
and early range of motion. tendon is divided at the level of the proximal

Fig. 13. Fractures at the base of the proximal phalanx are most easily noted on the lateral and oblique radio-
graphic views. Closed reduction can be maintained using crossed K-wires. These are removed in the office setting
at 4 to 6 weeks postoperatively and range-of-motion activities are instituted.
 Phalangeal Fractures 529

phalanx and the tendon flap with intact cen-

tral slip insertion is reflected distally

Midaxial Approach to the Phalanx

The midaxial approach allows exposure of the
lateral phalanges, IPJs, and collateral ligaments
for fracture fixation and PIPJ arthroplasty.48,51,52
It is indicated for oblique, spiral, comminuted, or
transverse fractures of the diaphysis and meta-
physis. It provides visualization of phalangeal frac-
tures for placement of internal fixation (either
screws or plates) on the radial or ulnar aspect of
the bone. Hardware is less likely to interfere with
tendon gliding in the midaxial than in a dorsal or
palmar position.
 The digit is flexed and the dorsal aspect of each
flexion crease is marked with a dot. The digit is
extended and these markings are connected to
create the incisional marking. The digital artery
and nerve will lie palmar to this line.
 The skin is incised, the soft tissues dissected,
and Clelands ligaments are divided to expose
the neurovascular bundle. The neurovascular
bundle is maintained in the palmar flap and
the periosteum of the phalanx can be visual-
ized. Palmarly, the flexor tendon sheath can
be identified.
Fig. 14. The central slip attachment to the dorsal base  Two structures limit the proximal dissection of
of the middle phalanx can result in avulsion of part of this approach: the dorsal branch of the digital
the articular surface, as seen in this lateral radiograph. nerve and the lateral band. The nerve should

Fig. 15. This unstable articular fracture of the middle phalangeal base was treated via ORIF using three 1.0-mm
screws.
530 Carpenter & Rohde

be identified and protected as it travels palmar system, and the skin is closed with interrupted
to dorsal over the proximal phalanx. The nylon sutures.
lateral band may be incised longitudinally or
even excised for better exposure of the prox- SPECIFIC SURGICAL TECHNIQUES
imal phalanx. Repair is optional if the contra- K-wire Insertion into Distal Phalanx
lateral lateral band is intact.
The tuft of the distal phalanx lies just volar to the
sterile matrix. Hence, the starting point for a
Volar Approach to the Middle Phalangeal Base
retrograde K-wire is just volar to the hyponychial
The volar approach to the middle phalangeal base fold (see Fig. 6). If the initial pass of the wire is
(or the PIPJ) is reserved primarily to address PIPJ unsatisfactory, leaving the errant wire in place
fracture-dislocations (also discussed in the article temporarily while passing the next can prevent
“Intra-Articular Fractures” by Lawton elsewhere the second wire from taking that initial course.
in this issue)27,48: The distal tip of the exposed wire can be trun-
cated beneath the skin or bent, truncated, and
 A modified Brunner incision is made centered covered with a protective cap until later
over the PIPJ. removal.
 A thick flap of soft tissue is elevated and re-
tracted to reveal the flexor tendon within the K-wire Cross-Pinning
pulley system.
 The A3 pulley is incised and reflected, allow- Crossed K-wire fixation is one of the most useful
ing retraction of the FDS and FDP tendons methods of fixation of phalangeal fractures.
radially and/or ulnarly. Confirmation of anticipated insertion point and
 The volar plate may already be avulsed (as in direction are made with the use of fluoroscopic
an acute PIPJ fracture dislocation pending imaging. The fracture is crossed by multiple
volar plate arthroplasty or acute fracture) or K-wires to promote rotational and translational
remain healed to the middle phalanx (as in stability (Fig. 17). Although K-wires have the po-
chronic or pilon injuries). If necessary, reflec- tential for migration, careful bending, truncating,
tion of the volar plate from the base of the mid- and protecting the end will help prevent this
dle phalanx allows visualization of the base of from becoming an issue. A useful technique also
the middle phalanx. is to drive the sharp end of the K-wire through
 Further middle phalangeal base exposure is the far cortex, through the skin, truncate the
facilitated by release of the collateral liga- sharp tip, and draw it back to the appropriate
ments in anticipation of “shotgunning” the length. This can minimize symptomatic irritation
joint in preparation for ORIF or hemihamate of soft tissues by the sharp point should the
autograft placement (Fig. 16). K-wire move. This fixation generally is supple-
 Following fixation, the volar plate is repaired, mented by a cast or brace; patients wearing a
the tendons realigned within the pulley removable brace are able to shower with running
water over the pins but should be cautioned
against soaking in standing water to prevent
infection.

Intraosseous Wiring
Intraosseous wiring involves passing a 26-gauge
wire transversely across the fracture line dorsal
to the midaxis and looping it around oblique
K-wires to help neutralize the rotational forces.
Although excellent success has been reported
using this technique for transverse fractures and
replants,53 it has become less popular in recent
years.

Tension Band Wiring

Fig. 16. The volar approach usually is used to treat
volar intra-articular injuries. Here, the volar approach Tension band wiring entails inserting K-wires
was used as described, allowing “shotgunning” of the across the fracture site and using supplemental
joint in preparation for hemi-hamate autograft 26-gauge wire looped around the protruding
reconstruction. K-wire ends to create a compressive force at the
 Phalangeal Fractures 531

Fig. 17. K-wires are inserted in a crossed fashion, aiming to achieve multidirectional stability and maintain
reduction.

fracture site. Useful for avulsion fractures, its ORIF Plate and Screws
popularity also has decreased, possibly sup-
As in compression screw fixation, ORIF using a
planted by the availability of suture anchors.
small plate and screws is technically difficult but
can provide unparalleled restoration of anatomy
Compression Screws with stability to allow immediate motion
Despite widespread familiarity of surgeons who (Fig. 18). T plates are typically used for phalanx
treat fractures with compression screw fixation, fractures.15 The plate is aligned perpendicular to
the unique anatomic considerations in the pha- the joint line and secured with a single screw.
langes (gliding structures, thin cortices, and small The distal portion of the fracture is then brought
fracture fragments with tenuous vascular supplies) into alignment and secured with an additional
render compression screw fixation one of the more screw. The length, angulation, and rotation are
technically difficult methods of phalanx fracture all assessed radiographically and clinically before
surgery. However, the stability achieved affords filling the plate with the remaining screws. Plate
the option of immediate mobilization, a distinct placement is relevant to outcome in the phalanx.
advantage over some other methods. The Lateral plate placement effectively resists
following general principles of compression screw compressive forces and has less disruption to
placement apply: the extensor mechanism and potentially less
risk of adhesions55 than dorsal plating. If a plate
 The screw diameter should not exceed one- is applied to the dorsal surface, care must be
third of the length of the fracture. taken to avoid damaging the flexor tendons with
 In the diaphysis, the fracture line itself should screws that are overdrilled.
be at least twice the diameter of the bone.
 At least 2 and preferably 3 screws should
External Fixation
cross the fracture site to provide multiplanar
stability (see Fig. 13B). External fixation of phalangeal fractures is useful if
 The fracture reduction should be held by there is extensive comminution requiring distrac-
either K-wires or a clamp. The tap drill, equal tion or if there is significant soft tissue disruption
to the core diameter for the chosen screw precluding internal fixation.42,45 Although rarely
size, is used to drill both the near and far needed, the authors prefer using the dynamic
cortices along a line halfway between a external fixator described by Ruland and
perpendicular to the phalangeal shaft and a colleagues.56
perpendicular to the fracture line. The near
cortex is then overdrilled with a drill bit that
Complications
is the same size as the screw’s outer diameter
to create a gliding hole. The screw is placed in Complications can arise with either nonoperative
a lag fashion to provide compression of the or operative management of phalangeal fractures.
fracture site.15,27,54 Potential complications include delayed union,
 It is not recommended to countersink the nonunion, malunion, soft tissue adhesions, joint
screw head in the metaphysis because of contractures, infection, posttraumatic arthritis,
the thin cortex.15 hardware issues, and tendon rupture.27,34,49,57
532 Carpenter & Rohde

Fig. 18. This unstable intra-articular fracture at the base of the proximal phalanx required early motion and was
too comminuted for simple screw fixation. Therefore, a buttress plate and screws were used. (Courtesy of Jennifer
M. Wolf, MD Farmington, CT)

Authors’ Preferred Method of Treatment 8. Kozin SH, Thoder JJ, Lieberman G. Operative
treatment of metacarpal and phalangeal shaft frac-
The authors treat phalangeal fractures guided by tures. J Am Acad Orthop Surg 2000;8(2):111–21.
the principles of restoring anatomy to maximize 9. Jupiter J, Axelrod TS, Belsky MR. Fractures and
function. In general, this entails minimizing joint dislocations of the hand. In: Browner BD,
stiffness and pain by restoring articular congruity, Green NE, editors. Skeletal trauma. 4th edition.
minimizing digit deformity and malrotation by Edinburgh (United Kingdom): Saunders; 2008. p.
addressing phalangeal shortening and angula- 1221–341.
tion, and preventing functional loss by achieving 10. Reyes FA, Latta LL. Conservative management of
early mobilization without compromising fracture difficult phalangeal fractures. Clin Orthop Relat
stability. In most cases, this can be accom- Res 1987;(214):23–30.
plished without surgery. However, in the case 11. Maitra A, Burdett-Smith P. The conservative man-
of an unstable fracture or one that unacceptably agement of proximal phalangeal fractures of the
disrupts the articular surface, operative fixation hand in an accident and emergency department.
balancing the goals of fracture healing, soft tis- J Hand Surg Br 1992;17(3):332–6.
sue preservation, and early return to function is 12. Barton NJ. Fractures of the shafts of the phalanges
preferred. of the hand. Hand 1979;11(2):119–33.
13. Moberg E. Fractures and ligamentous injuries of
REFERENCES the thumb and fingers. Surg Clin North Am 1960;
40:297–309.
1. Watson-Jones R, Wilson JN. Fractures and joint 14. Day C, Stern P. Fractures of the metacarpals and
injuries, 6th edition. Edinburgh (United Kingdom), phalanges. In: Green DP, editor. Green’s operative
New York: Churchill Livingstone; 1982. hand surgery. 5th edition. Philadelphia: Elsevier/
2. James JI. Fractures of the proximal and middle Churchill Livingstone; 2005. p. 239–90.
phalanges of the fingers. Acta Orthop Scand 15. Harman TW, Graham TJ, Uhl RL. Operative treat-
1962;32:401–12. ment of extra-articular phalangeal fractures. In:
3. James JI. The assessment and management of the Wiesel SW, editor. Operative techniques in ortho-
injured hand. Hand 1970;2(2):97–105. paedic surgery. 1st edition. Philadelphia: Lippincott
4. Barton B. Fractures of the hand. J Bone Joint Surg Williams & Wilkins; 2012. Chapter 32 p. 2378–91.
Br 1984;66(2):159–67. 16. Schneider LH. Fractures of the distal phalanx.
5. Swanson AB. Fractures involving the digits of Hand Clin 1988;4(3):537–47.
the hand. Orthop Clin North Am 1970;1(2): 17. Sloan J, Dove A, Maheson M, et al. Antibiotics in
261–74. open fractures of the distal phalanx? J Hand Surg
6. Van Onselen EB, Karim RB, Hage JJ, et al. Preva- Br 1987;12(1):123–4.
lence and distribution of hand fractures. J Hand 18. Roser SE, Gellman H. Comparison of nail bed repair
Surg Br 2003;28(5):491–5. versus nail trephination for subungual hematomas
7. Gaston RG, Chadderdon C. Phalangeal fractures: in children. J Hand Surg Am 1999;24(6):1166–70.
displaced/nondisplaced. Hand Clin 2012;28(3): 19. Krusche-Mandl I, Köttstorfer J, Thalhammer G,
395–401. et al. Seymour fractures: retrospective analysis
 Phalangeal Fractures 533

and therapeutic considerations. J Hand Surg Am 36. Chung KC, Spilson SV. The frequency and epidemi-
2013;38(2):258–64. ology of hand and forearm fractures in the United
20. Schneider LH. Fractures of the distal interphalan- States. J Hand Surg Am 2001;26(5):908–15.
geal joint. Hand Clin 1994;10(2):277–85. 37. Feehan LM, Sheps SB. Incidence and demo-
21. Seymour N. Juxta-epiphysial fracture of the termi- graphics of hand fractures in British Columbia,
nal phalanx of the finger. J Bone Joint Surg Br Canada: a population-based study. J Hand Surg
1966;48(2):347–9. Am 2006;31(7):1068–74.
22. Dolan M, Water P. Fractures and Dislocations of 38. Coonrad RW, Pohlman MH. Impacted fractures in
the forearm, wrist, and hand. In: Green NE, the proximal portion of the proximal phalanx of the
Swiontkowski MF, editors. Skeletal trauma in chil- finger. J Bone Joint Surg Am 1969;51(7):1291–6.
dren. 4th edition. Philadelphia: Saunders/Elsevier; 39. Schenck RR. Classification of fractures and dislo-
2009. p. 159–205. cations of the proximal interphalangeal joint.
23. Rider DL. Fractures of the metacarpals, metatar- Hand Clin 1994;10(2):179–85.
sals, and phalanges. Am J Surg 1937;38(3): 40. Calfee RP, Kiefhaber TR, Sommerkamp TG, et al.
549–59. Hemi-hamate arthroplasty provides functional
24. Moss JG, Steingold RF. The long term results of reconstruction of acute and chronic proximal inter-
mallet finger injury. A retrospective study of one phalangeal fracture-dislocations. J Hand Surg Am
hundred cases. Hand 1983;15(2):151–4. 2009;34(7):1232–41.
25. Handoll HH, Vaghela MV. Interventions for treating 41. Inanami H, Ninomiya S, Okutsu I, et al. Dynamic
mallet finger injuries. Cochrane Database Syst external finger fixator for fracture dislocation of
Rev 2004;(3):CD004574. the proximal interphalangeal joint. J Hand Surg
26. Weiss AP, Hastings H. Distal unicondylar fractures Am 1993;18(1):160–4.
of the proximal phalanx. J Hand Surg Am 1993; 42. Parsons SW, Fitzgerald JA, Shearer JR. External
18(4):594–9. fixation of unstable metacarpal and phalangeal
27. Henry M. Hand fractures and dislocations. In: fractures. J Hand Surg Br 1992;17(2):151–5.
Rockwood CA, Green DP, Bucholz RW, editors. 43. Geissler WB. Operative fixation of metacarpal and
Rockwood and Green’s fractures in adults. 7th edi- phalangeal fractures in athletes. Hand Clin 2009;
tion. Philadelphia: Wolters Kluwer Health/Lippincott 25(3):409–21.
Williams & Wilkins; 2010. p. 710–829. 44. Stern PJ. Management of fractures of the hand
28. Chamay A. A distally based dorsal and triangular over the last 25 years. J Hand Surg Am 2000;
tendinous flap for direct access to the proximal 25(5):817–23.
interphalangeal joint. Ann Chir Main 1988;7(2): 45. Slade JF, Baxamusa TH, Wolfe SW. External fixation
179–83. of proximal interphalangeal joint fracture-disloca-
29. Al-Qattan MM. Phalangeal neck fractures in chil- tions. Atlas of the Hand Clin 2000;5(1):1–29.
dren: classification and outcome in 66 cases. 46. Kuhn KM, Dao KD, Shin AY. Volar A1 pulley
J Hand Surg Br 2001;26(2):112–21. approach for fixation of avulsion fractures of the
30. Al-Qattan MM. Phalangeal neck fractures in adults. base of the proximal phalanx. J Hand Surg Am
J Hand Surg Br 2006;31(5):484–8. 2001;26(4):762–71.
31. Al-Qattan MM. Phalangeal neck fractures of the 47. Hastings H, Carroll C. Treatment of closed articular
proximal phalanx of the fingers in adults. Injury fractures of the metacarpophalangeal and prox-
2010;41(10):1084–9. imal interphalangeal joints. Hand Clin 1988;4(3):
32. Horton TC, Hatton M, Davis TR. A prospective ran- 503–27.
domized controlled study of fixation of long oblique 48. Catalano LW, Zlotolow DA, Purcelli Lafer M, et al.
and spiral shaft fractures of the proximal phalanx: Surgical exposures of the wrist and hand. J Am
closed reduction and percutaneous Kirschner Acad Orthop Surg 2012;20(1):48–57.
wiring versus open reduction and lag screw fixa- 49. Kurzen P, Fusetti C, Bonaccio M, et al. Complica-
tion. J Hand Surg Br 2003;28(1):5–9. tions after plate fixation of phalangeal fractures.
33. Orbay JL, Touhami A. The treatment of unstable J Trauma 2006;60(4):841–3.
metacarpal and phalangeal shaft fractures with 50. Bickel KD. The dorsal approach to silicone implant
flexible nonlocking and locking intramedullary arthroplasty of the proximal interphalangeal joint.
nails. Hand Clin 2006;22(3):279–86. J Hand Surg Am 2007;32(6):909–13.
34. Balaram AK, Bednar MS. Complications after the 51. Field LD, Freeland AE, Jabaley ME. Midaxial
fractures of metacarpal and phalanges. Hand approach to the proximal phalanx for fracture fixa-
Clin 2010;26(2):169–77. tion. Contemp Orthop 1992;25:133–7.
35. Shewring DJ, Thomas RH. Avulsion fractures from 52. Carlson MG, Szabo R, Lipscomb P. Principles of
the base of the proximal phalanges of the fingers. hand surgery and surgical approaches to the hand
J Hand Surg Br 2003;28(1):10–4. and wrist. In: Chapman MW, editor. Chapman’s
534 Carpenter & Rohde

orthopaedic surgery. 3rd edition. Philadelphia: proximal phalangeal fracture model. J Hand Surg
Lippincott Williams & Wilkins; 2001. p. 1226–46. Am 1996;21(6):1059–64.
53. Zimmerman NB, Weiland AJ. Ninety-ninety intra- 56. Ruland RT, Hogan CJ, Cannon DL, et al. Use of
osseous wiring for internal fixation of the digital dynamic distraction external fixation for unsta-
skeleton. Orthopedics 1989;12(1):99–103. ble fracture-dislocations of the proximal inter-
54. Perren SM, Allgöwer M, Osteosynthesefragen AF. phalangeal joint. J Hand Surg Am 2008;33(1):
Manual of internal fixation: techniques recommen- 19–25.
ded by the AO-ASIF Group. Berlin, New York: 57. Page SM, Stern PJ. Complications and range of
Springer-Verlag; 1991. motion following plate fixation of metacarpal and
55. Lins RE, Myers BS, Spinner RJ, et al. A compara- phalangeal fractures. J Hand Surg Am 1998;
tive mechanical analysis of plate fixation in a 23(5):827–32.