Fracture Handbook

  

3. Middle Phalanx

3.1. Middle Phalanx Base (outside the joint)


These are surprisingly uncommon injuries. If there is little or no shift between the two halves of the break then the finger is protected in a splint or plaster for around 3 weeks. Further X-rays will be needed to ensure the fragments do not move in the first 1-2 weeks. After 3 weeks or so the patient can start protected movement.
If the two halves are displaced they will need to be pushed back into place. This may be stable enough to hold the break just with a plaster or splint. If not (this is often a judgment for the surgeon) then the break will need to be held with one or more wires. Under local or general anaesthetic the wires are put in through the skin without opening up the break.
The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.

3.2. Middle Phalanx Base (Intra-articular)


Typically this will either be a Pilon fracture which is a complex smash up of the joint, or a dorsal fracture subluxation/dislocation where there is a break at the front of the joint and the rest of the base of the middle phalanx tips out the back of the joint. Much less common are volar fracture dislocations where the base of the middle phalanx goes forward and not backwards, and central slip avulsion fractures i.e. a pull off of the tendon at the back of the joint.

A: Pilon fractures
A typical pilon fracture is a direct end on injury with impaction and splaying of the articular surface at the base of the middle phalanx, If the overall alignment is reasonable and there is good early joint movement i.e. at least half early on then careful observation should suffice. The finger is protected in a splint for the first 2 weeks and then careful movement is started with physiotherapist support. Repeat X-rays should be taken at around 10 days to ensure there is no further significant displacement, but in our experience if there is reasonable early movement these fractures are stable and do not move out of alignment later on.
If there is significant displacement or poor early movement, some form of a dynamic traction device typically a K-wire external fixator works very well. This should be applied under local anaesthetic. Some specialists recommend open reduction and internal fixation with screws but this is fraught with hazards and gives less reliable results.
We remove the pins in the outpatients' clinic at about 4 ½ to 5 weeks from operation. This is normally long enough to ensure a stable articular surface to the base of the middle phalanx and return of a good range of movement. The risk of infection along the tracks of the pin in this period is small but increases after the pins have been in for 5 weeks in our experience.
Neglected injuries will generally have a poor outcome with severe restriction in motion and large fixed flexion deformities. Pain may also accompany these deficits. Early diagnosis and treatment is therefore of great importance.

B: Dorsal fracture subluxation/dislocation
Almost all of the PIPJ subluxations or dislocations are fracture subluxations i.e. partial not complete displacement of the joint. They are colloquially referred to as fracture dislocations and many may well have dislocated and reduced in part and hence present as subluxations. If the PIPJ has reduced fully with a small bony pull-off fragment (the former distal attachment of the volar plate), as occurs with most simple hyperextension i.e. tip back injuries, these should be treated with early mobilisation and discharged to the Hand therapist. The main concern with these injuries is late stiffness rather than late instability. It is therefore important to maintain movement. Recurrent dislocation is very rare. About 1 in 20 patients will require a steroid injection at around 6 weeks, because of persistent swelling and stiffness. This usually gives a very good long-term result.
Occasionally the dislocated proximal phalangeal head may tear through the skin on the front of the finger and present as an open injury. The management includes reduction of the joint and wash out of the wound with closure of the wounds. This can be done under a local anaesthetic in the A & E department with an excellent functional outcome.
If there is a larger bone break on the front there may be dorsal subluxation of the main middle phalanx fracture fragment. This should be looked for very carefully on a true lateral film. The subluxation needs to be reduced. If the volar fracture fragment is less than 20-30% of the joint surface on the side view X-ray, then this can often be pushed back with the finger bent and held in POP. The PIP joint can be flexed up to about 50° for a week and then gradually reducing that over the next few weeks, aiming to get to about 10° at 3 weeks. For larger fragments or if the dislocation does not reduce on flexion the alternatives are a dynamic external fixator or a single 1.1mm K wire.
If a single 1.1mm wire is the construct is protected with a plaster or a splint for around 4 weeks, but not beyond 5 weeks. The DIP joint (end joint of the finger should be moved whilst the PIP joint is immobilised.

With greater fracture fragments some form of traction device will almost certainly be needed, such as the dynamic external fixator. This should be kept on for between 4 and 5 weeks and will need physiotherapy support, concentrating on both PIP but also DIP joint movement whilst the fixator is on and following its removal. If the patient is struggling to mobilise with the splint on then an injection of local anaesthetic and gentle manipulation may help encourage movement.

C: Volar fracture dislocations
These are much less common but the same principles apply as for dorsal fracture subluxation/dislocations. Again the key is reduction of the main joint fragment of the base of the middle phalanx onto the end of the proximal phalanx. This can be held with a wire or dynamic external fixator. The dorsal fragments will rarely reduce perfectly. This implies some lengthening and thus dysfunction of the central slip mechanism. This will lead to some mild stiffness and deformity. This is inevitable but does not preclude a good result and attempts at open surgery will often increase complications.

D: Central slip avulsion
This represents a lengthening of the extensor (straightening) tendon system. For most cases the treatment is as for soft tissue only boutonniere injuries i.e. central slip ruptures. The key is to hold the PIP joint in extension for 6 weeks whilst ensuring active DIP joint flexion. Thereafter gradual increasing motion is built up over the next 2 weeks. Again a good result with a fixed flexion deformity of 10 - 200 but full flexion can be expected.

 


3.3. Middle Phalanx - Mid-part of the bone


The patterns are typically as for those of the proximal phalanx and the treatments essentially the same.

(A) Transverse (straight across the bone)
If there is no tip or gap between the two halves of the break then initial protection for 1-3 weeks and movement from there gives very good results although many patients end up with a little stiffness in the finger. If there is a marked tip between the two halves of the break we first try to correct the tip with a push under local anaesthetic. This is often very successful. The finger is supported in a plaster cast for 3-4 weeks and moved carefully from there. Again a good outcome is expected, but with some finger stiffness.
If the break remains tipped or corrects and then tips back we usually wire the break along the line of the finger. The wire typically remains in place for 4-5 weeks. During this time the break and wire will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.


(B) Crush injury
Typically these are stable fractures and often will do well with support in a plaster for the first two weeks and then careful movement. Inevitably with the severe damage to the soft tissues like skin, nerves, arteries tendons, and ligaments, there will be some stiffness, cold aching, swelling and possibly some loss of feeling.

With even more severe crush injuries the soft tissues may burst open. These will be less stable injuries and may need some support such as with a wire frame called an external fixator.

(C) Short oblique (short diagonal) breaks
Short oblique fractures are typically unstable even after being straightened out reduction. If there is only mild displacement or shortening such as 2-3 mm the finger can usually be supported in a plaster and watched carefully for 2-3 weeks. Careful movement can begin from 4-5 weeks after injury..
If the break is unstable following straightening we usually hold it with 1-3 wires inserted through the skin and avoiding opening the finger. The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.
An alternative is to open the finger and fix the fracture with screws or a plate and screws but this is rarely necessary in our experience.


(D) Long oblique (long diagonal) break
These will often shorten by 1 or 2 mm, but hold a reasonable position with only mild tip. This usually needs no further treatment other than support in plaster for 3-4 weeks and then careful movement.
If the break has moved too much or will not hodl a good position after straightening then we recommend a push under local anaesthetic and holding the position with 3-4 wires passed through the skin and across the break. This is guided by X-rays in the operating theatre. The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries. Inevitably there will be long-term X-ray changes of arthritis in the injured joint but most people do not develop problems from this.
Most patients do well but there is often a little long-term stiffness in the middle joint of the finger.
(E) Spiral break
This is a common injury do to a twisting wrench of the finger. It often follows a fall whilst hoding a dog lead or horse reains, or carrying a bag such as a handbag or shopping. The concern is that the break will heal with a twist making function of the hand more difficult. The significance of the break is easy to miss soon after injury as twist of the finger can be difficult to assess early on.

 

3.4. Middle Phalanx Neck (outside the joint)


These are usually breaks straight across the bone which tip back. It occurs most commonly in late childhood and adolescence in adolescents. If there is little or no shift between the two halves of the break then the finger is protected in a splint or plaster for around 3 weeks. Further X-rays will be needed to ensure the fragments do not move in the first 1-2 weeks. After 3 weeksor so the patient can start protected movement.
If the two halves are displaced they will need to be pushed back into place. This may be stable enough to hold the break just with a plaster or splint. If not (this is often a judgment for the surgeon) then the break will need to be held with one or more wires. Under local or general anaesthetic the wires are put in through the skin without opening up the break.
The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.
3.5. Middle Phalanx- Distal - (into the joint)
If there is little or no shift between the two halves of the break then the finger is protected in a splint or plaster for around 3-4 weeks. Further X-rays will be needed to ensure the fragments do not move in the first 1-2 weeks. After 3 weeksor so the patient can start protected movement.
If the two halves are displaced they will need to be pushed back into place. This is rarely stable enough to hold with a plaster or splint. In most cases the break will need to be held. Under local or general anaesthetic 1-4 wires are passed through the skin or the break is opened and the fracture fixed with 1-2 screws wires. Under local or general anaesthetic the wires are put in through the skin without opening up the break.
If wires are used they typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. If screws are used then minimal if any extra support is needed and the patient is encouraged to start gentle movement of the finger straightaway. Most patients do very well following these injuries.

 

 

 

 

 

 

 

 

 

 
 

The Hand to Elbow Clinic
29a James Street West
Bath BA1 2BT

Tel 01225 316895
Fax 01225 484949
info@handtoelbow.com
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