Slideshow
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Figure 1. Anteroposterior radiography view of injured finger.
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Figure 2. Oblique view of injured finger.
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Figure 3. Lateral view of injured finger in flexion.
A 22-year-old man presents with right-hand pain after the dock he was installing suddenly fell, crushing his fifth digit between the boards. On physical examination, the patient has pain to palpation over the proximal phalanx and his skin is intact. The proximal phalanx is slightly deviated toward the ulnar but the finger does not appear rotated. Radiographs are taken (Figures 1-3).
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Proximal phalanx fractures of the hand can be unstable fractures because of the deforming forces placed on the bone. The interosseous muscles insert on the base of the proximal phalanx and can flex the proximal fracture fragment while the flexor and extensor tendons apply a shortening force to the fracture. The most stable nondisplaced transverse fractures can withstand these deforming forces, however, the unstable displaced, comminuted, or oblique fracture patterns tend to displace.1,2
Nondisplaced fractures can be treated with immobilization with the metacarpophalangeal (MCP) joint in 70˚ to 90˚of flexion, which reduces the displacing forces of the surrounding soft tissue. A removable boxer fracture splint is a good option for patients who can adhere to treatment, otherwise, an ulnar gutter cast may be required. 1,2
Immobilization for 3 weeks is recommended or until fracture healing is found on radiograpy, at which time buddy tapping can be resumed for another 3 weeks. Buddy taping can also help with initial immobilization to help with rotational stability. 1,2
Fractures that are displaced, shortened, and unstable often require surgery. Relative indications for surgery include fractures that are angulated, malrotated, or shortened by more than 5 mm. Shortened fractures can result in an extension lag to the finger. 1,2
Percutaneous fixation is often performed for displaced proximal third fractures whereas middle and distal third fractures are often treated with open reduction and internal fixation. Because displaced fractures are unstable, closed reduction and casting are usually not an option unless patients have a contraindication to surgery.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Lögters TT, Lee HH, Gehrmann S, Windolf J, Kaufmann RA. Proximal phalanx fracture management. Hand (N Y). 2018;13(4):376-383. doi:10.1177/1558944717735947
2. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. 2000;8(2):111-121. doi:10.5435/00124635-200003000-00005
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