This document summarizes fractures and dislocations of the phalanges. It begins with anatomy of the hand and mechanisms of injury. It then discusses specific fracture patterns including tuft, shaft, mallet finger and jersey finger injuries. Treatment options are provided for each including splinting, pinning and open reduction techniques. Complications are also summarized. MCP dislocations of the thumb are reviewed including mechanisms, types and methods of closed and open reduction.

1. PHALANGEAL
FRACTURES and
DISLOCATONS
Presenter : Dr Darshan K S(2nd year post graduate)
Moderator: Dr P AGNESH
Assistant professor of orthopaedics
Unit Chief : Dr G Ramesh
Professor of Orthopaedics

2. ANATOMY
• Meatcarpophalangeal joint- Condyloid joints
• ROM at MCPJ- flexion and extension of the digits, as well as a very small
degree of abduction and adduction when the digits are extended.
• Phalanges - has a base, shaft, neck and head that is formed from two
condyles.
• PIPJ, DIPJ - Hinge joints,
ROM at PIP and DIP joint : flexion and extension.

3. VERDAN’S ZONES OF HANDS

4. The joint capsule is
reinforced on its volar aspect
by the thickened ligament
known as the VOLAR PLATE
that prevents hyperextension
of the joint

5. • Vinculum breve and
Vinculum longum are known
to serve as transport and
conduction pathways to the
intravaginal segments of flexor
tendons.
• The Vinculum breve is
regarded as essential for
maintaining the tendons at
work. In contrast, the
significance of Vinculum
longum will be variable for
the microcirculation of
intravaginal segments of the

7. 1. Axial load or “jamming” injuries ,
– shearing articular fractures or metaphyseal compression
fractures.
– catching a falling object
2. Bending – Diaphyseal fractures and joint dislocations
– ball-handling sports or when the hand is trapped.
3. Torsional – Spiral fractures
– Individual digits can easily be caught in clothing, furniture, or
workplace equipment
4. Crushing – Bending + shearing + torsion.
– with significant soft tissue injury
MECHANISMS OF INJURY

8. Associated injuries
Open injuries –
• Need for prophylactic antibiotics ?
• Previous standard administration of Ceftriaxone is no longer implacable due to MRSA
dominating community acquired infection profile.(clinda,vanco)
• Continuation of antibiotics beyond 24 hours.?
• Soft tissue reconstruction and use of flap essential for overlying skeletal injury.
Tendons.
• Eg: Terminal tendon rupture a/w DIP,
Central slip rupture a/w PIP.
Nerves and vessels
Massive hand trauma.
Bone loss

11. FUNCTIONAL STABILITY
• Fractures as functionally stable - if patients could actively move the
adjacent joint more than 30% of the expected range while the
alignment of fracture remained within acceptable range.
• Unstable fracture - If the patient was not able to move the adjacent
joint more than 30% of the expected range or movement resulted in
malalignment.

12. DISTAL PHALANX FRACTURES
• Terminal point of contact . Therefore experiences stress loading forces.
• Soft tissue injury is of greater significance
• Hematoma can be seen beneath the nail plate- nail bed injury
• Mechanism – crushing.
• Radiographs - isolated views of the injured digit.

13. The proximal part of the pulp is
thicker and more mobile than the
distal pulp.
The proximal portion of a tuft
fracture may become entrapped in
the septae of the pulp and prove
irreducible.
The dorsal surface of the distal
phalanx is the direct support for the
germinal matrix and sterile matrix of
the nail.
The bone volarly and the nail plate
dorsally create a three-layered
sandwich with the matrix in the
middle

14. ASSOCIATED INJURIES :
– Nailbed lacerations
– Nail plate avulsion
– Skin lacerations
– Subungal hematoma

15. PATHOANATOMY
• Shaft fracture
• – Transverse fracture
• – Longitudinal
• Tuft fracture (associated with nail bed fracture and open fracture)
• Dorsal Base (Mallet finger)
• Volar base ( Type III Jersey finger)
• Salter-Harris
• The two mechanisms .
– sudden axial load (as in ball sports)
– crush injury

16. • Crush fractures of the tuft are often
stable.
• Majority of bone flakes at the volar base
P3 are FDP tendon ruptures.
• Dorsal base IA # with shearing force will
have intra articular extension(>20%) and
should be distinguished from avulsion
fracture.

18. MALLET FINGER
• Doyle’s classification for
Mallet Finger Classification :
TYPE 1 :Closed/blunt trauma No fracture,
loss of tendon continuity with or without
a
small avulsion fracture
(full extension or hyperextension in the DIP
joint).
Maintain for 8 weeks,
Use for 2-6 weeks nightime.
Molded polythene (Stack) or aluminum
splint.

19. • TYPE 2 : Lacerations at or
proximal to distal
interphalangeal joint with
loss of tendon continuity.
• (SUPERFICIAL SOFT TISSUE
INJURY)
Direct repair of the extensor tendon
can be done by tendon suture repair
and Kirschner wire fixation of the distal
interphalangeal joint in full extension.

20. • TYPE 3 : Deep abrasion with loss
of skin ,subcutaneous cover and
tendon substance.
• (DEEP SOFT TISSUE INJURY)
Require soft-tissue coverage and
pinning of the distal interphalangeal
joint and possible primary
arthrodesis.

21. Type 4: 4A, transphyseal fracture in
children.
4B, hyperflexion injury with
fracture of articular surface of 20%
to 50%.
4C, hyperextension injury
with fracture of the articular
surface usually greater than 50%
with early or late volar subluxation
of the distal phalanx.

22. Closed reduction with Extension Block Pinning
• 6 Weeks: Remove kwire, wean from splint use
• 3 Months: Resume full activities. Assess ROM.
EXTENSION BLOCK PINNING

23. OPEN REDUCTION AND
FIXATION WITH A PULL-OUT
WIRE AND TRANSARTICULAR
KIRSCHNER WIRE

24. JERSEY FINGER (FLEXOR TENDON AVULSION)
• Type I-
Vincula ruptured with
tendon retracted to the palm.
Leads to disruption of the
vascular supply.
Able to fully flex PIP joint.(If
FDS intact)
– Exploration and Primary
repair within 10 days

25. • TYPE 2 :
FDP retracts to level of
PIP joint.
Unable to flex DIP and PIP
joint.
• Primary repair as soon as
possible.
• Primary repair may still be
possible several weeks.

26. • TYPE 3:
Large avulsion fracture
limits retraction to the level
of the DIP joint
• Repair of fracture fragment (6
weeks)

27. • TYPE 4 :
Osseous fragment and simultaneous
avulsion of the tendon from the fracture
fragment ("Double avulsion” with
subsequent retraction of the tendon usually
into palm)
If tendon separated from fracture fragment,
first fix fracture via ORIF then reattach tendon
as for Type I/II injuries

28. ANCHOR SUTURE TECHNIQUE
DORSAL BUTTON TECHNIQUE

30. Jersey Finger Follow-up Care
• Splint for 4-6 weeks
• Begin passive flexion exercises at one week
• Remove suture/button at 4 weeks and begin
protected active motion
• Continue activity limitations for 12 weeks.

31. TUFT FRACTURES
• Splinted in a simple
aluminum and foam
splint.
• When the seal of the nail
plate with the
hyponychium has been
broken and the tuft
fracture is displaced, this
represents an open
fracture, that should be
treated on the day of
injury with debridement K-wires for 4 to 6 weeks.

33. SHAFT FRACTURES
 Splinted with stack/
aluminium splints for
undisplaced
fractures.
 Headless screws
 Kirshner wire fixation.

35. Middle Phalanx (P2) Fractures
• Head, neck, shaft, and base.
• Intra-articular fractures that occur at the base of the middle phalanx are most
functionally devastating of all fractures.
• The most technically difficult to treat.

36. • Unicondylar or bicondylar fractures of the head.
• Partial articular fractures
– Dorsal base
– Volar base
– Lateral base
• Complete articular fractures
– “pilon” fractures. “
– Unstable in every direction including axially.

38. • Static Splinting.
– Comminution with no significant displacement.
• Dynamic Extension Block Splinting.
– Volar base of P2 - less than 40% of the articular surface.
• Condylar fractures
– CRIF- converging or diverging k wires.
• Unstable shaft fractures
– CRIF – K wiring
– ORIF – Lag screw fixation – if rotational instability.
– Plate and screw fixation – if axial instability.
Middle Phalanx Fracture- Treatment Options

39. Extension block splinting
Diverging and converging k- wires

41. • Temporary Transarticular Pinning for Partial Articular Base Fractures.
• Volar Base Fractures
– CRIF /ORIF
• Pilon fractures.
– Highly unstable,stiffness of PIPJ.
– Dynamic traction / dorsal spring mechanism.
– The general principle is to establish a foundation at the center
of rotation in the head of Proximal phalanx.
– traction (adjustable or elastic) is applied along the axis of P2
to hold the metaphyseal component of the fracture out to
length.

42. Volar base fracture fixation
Strategies for PILON fracture fixation

43. Custom hook plate for dorsal base fratcures
Lag screw fixation for dorsal base fracture

46. External fixation frame

47. HINGED EXTERNAL FIXATOR

49. PROXIMAL PHALANGES FRACTURES
• Head - Intraarticular fractures
– partial or complete articular
• Neck - extra-articular fractures
– (extreme PIPJ limitation)
• Base - extra-articular and intra-articular.
• Shaft -extra-articular fractures
– transverse, short oblique, long oblique, or spiral

51. PATHO ANATOMY
• Sheet-like extensor mechanism with a complex array of decussating
collagen fibers.

53. P 1 – Treatment options
• Non operative.
– Stable proximal fractures, Transverse shaft.
– Dorsal splinting with the MP joint in flexion.
– discontinued at 3 weeks, followed by AROM .
– Stable + undisplaced – immediate AROM with buddy
strapping.
– Weekly follow up.
Ball and bandage tech for base of proximal phalanx
• Operative – CRIF/ORIF

54. Closed Reduction + Internal Fixation
• Reducible but unstable isolated fractures.
• For long oblique and spiral fractures
– three K-wires- perpendicular to the fracture
• For neck fractures-
– retrograde pinning may be necessary
• For short oblique and transverse fractures,
– longitudinal K-wires .

60. Open Reduction and Internal Fixation
• Indications :
– Open fractures
– multiple fractures
– intra-articular fractures with displacement
– Spiral fractures
• lag screws
• to achieve precise control over rotation.

71. Postoperative Care – P 1 fracture
• Non operative
– Restrict splinting to 3 weeks followed by AROM.
• CRIF
– pin removal at 3 weeks start AROM.
• ORIF
– AROM should begin within 72 hours of surgery and edema control

75. DISLOCATIONS AT INTERPHALANGEAL JOINT

77. • Interphalangeal joint dislocations often cannot be
reduced with closed techniques.
• Entrapment of the lateral band around the head of the
proximal phalanx may block reduction, and open
reduction may be necessary.

79. SAFE CORRIDORS IN FINGERS
• It is the area where k – wire can be passed
with minimal soft tissue trauma and
without damaging vital structures like
extensor expansion, neurovascular
structures and flexor tendons.
• This allows relatively pain free active range
of movements and prevent stiffness.

80. SAFE CORRIDOR IN HAND

83. Paediatric mallet finger
• Pediatric mallet fingers or Seymour fractures should be treated with closed
reduction and splinting of the distal interphalangeal joint in neutral or slight
extension for 4 weeks.
• Open reduction and Kirschner wire fixation of the epiphyseal fragment is
indicated if closed reduction cannot be obtained.
• Remove the k wire within 2 weeks and start early mobilization if the k wire
is inserted through the epiphysis.

84. • ROCK WOOD AND GREENS, FRACTURES IN ADULTS – 8 th edition.
• Charles M Court Brown
• James D Heckman
• Margaret M Mcqueen
• William M Ricci
• Paul Tornetta
• Campbell’s Operative Orthopaedics, 14th edition.
• Fredrick M Azar
• James H Beaty
• A O principles of fracture management
• K wiring principles and techniques
• C REX

85. THANK YOU

86. MCP dislocation of thumb
• Thumb is second most common digit involved
MECHANISM OF INJURY
• Usually a fall on outstretched hand leading to hyperextension of
MCP joint leads to avulsion of the volar plate from metacarpal
neck
• Associated conditions
Metacarpal and phalanx fractures of the base of proximal phalanx or
metacarpal head
• seen in up to 50%

87. Simple (subluxation) : No interposition of volar plate and/or sesamoid Base
of proximal phalanx remains in contact with the metacarpal head.
COMPLEX :Interposition of volar plate and/or sesamoidsMetacarpal head
becomes entrapped by
-displaced natatory ligaments distally
-superficial transverse metacarpal ligament proximally

88. •Complex dislocation - joint space widening may indicate
interposition of volar plate .
•Entrapment of sesamoid in MCP joint is diagnostic of
complex dislocation
Radiograph findings:

89. Closed Reduction:
•Dorsal dislocation reduction technique:
•Apply direct pressure over dorsal aspect of proximal phalanx with the wrist in flexion to
take tension off the intrinsic and extrinsic flexors.
•Avoid longitudinal traction during closed reduction as it may pull volar plate into joint
and convert to irreducible immobilization.
•Early ROM and dorsal blocking splint following successful reduction

90. Complications
• Stiffness
• Malunion
• Non union
• Tendon rupture
• Hypersentivity syndrome
• Post traumatic Arthritis
• Premature physeal closure in paediatric age groups