Fractures of the distal phalanx are common hand fractures, especially involving the thumb, index, and middle fingers. They can result from crush injuries, sports injuries, or hyperextension against a flexed finger. Treatment depends on the type of fracture but may include splinting for non-displaced fractures or closed reduction and pinning for displaced fractures. Mallet finger injuries can be treated with splinting while jersey finger injuries often require surgical repair of the avulsed flexor tendon. Complications can include malunion, tendon adherence, nonunion, or stiffness if immobilization is too long.

1. Distal phalanx
fracture
Naranjargalan,.MD
November2,2015
20th presentation

2. Fractures of the Distal Phalanx
• The distal phalanx is common fracture in the
hand. (15-19% of hand fracture in adults)
• Especially injuries involving the thumb, index
and middle fingers.

3. Fractures of the Distal Phalanx
• Anatomy
– Extensor and
flexor tendons
insert into the
base of the
distal phalanx

4. Fractures of the Distal Phalanx
• Mechanism of Injury
– Crush injury
– Sport-related injury
– Sudden extension against a
flexed finger (rugger jersey)
– Sudden flexion against an
extended finger (baseball
hitting end of extended
finger)

5. Fractures of the Distal Phalanx
Classification
• 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

6. • Salter-Harris

7. Fractures of the Distal Phalanx
• Associated Injuries
– Nailbed lacerations
– Nail plate avulsion
– Skin lacerations
– Subungal hematoma
• Physical Exam
– Check both flexor and
extensor function
– Sensory exam

8. Fractures of the Distal Phalanx
Treatment
• Non-displaced or minimally displaced can
use variety of splints. /transverse fracture/
Tight circumferential taping should not be
used because of an increased risk of
circulatory compromise. Splinting is generally
maintained for about 2-3 weeks. If necessary
provided use until 6 weeks.

9. Fractures of the Distal Phalanx
Treatment
• Open fractures with
nailbed laceration
• stitches using 8.0
absorbable suture
material should be
used. Be careful to
suture the edges of the
nail bed

10. Fractures of the Distal Phalanx
Treatment
• DIP Dislocation
• AP, lateral + oblique
view of affected finger.
Mallet finger

11. Fractures of the Distal Phalanx
Treatment
• Mallet Finger
Classification
1. Closed No fracture
(full extension or
hyperextension in the DIP
joint)
• Maintain for 8weeks,
followed by nightime
splint use for 2-3 weeks.

12. Fractures of the Distal Phalanx
Treatment
• Mallet Finger
Classification
2. Open = lacerations
• repaired with running
suture

13. Fractures of the Distal Phalanx
Treatment
• Mallet Finger
Classification
3. Closed with fracture
• closed reduction
with Extension Block
Pinning= K-wire
• 6 Weeks: Remove k-
wire, wean from splint
use
• 3 Months: Resume full
activities. Assess ROM.

14. • K-wire

15. Incisions
• Dorsal to the DIP joint
incision
• Dorsal to IP joint of the
thumb incision

16. Fractures of the Distal Phalanx
• Jersey finger (Flexor
Tendon Avulsion)
Anatomy
– Flexor digitorum
profundus tendon
inserts into the base of
the distal phalanx

17. Fractures of the Distal Phalanx
• Mechanism of Injury
– Hyperextension
against a flexed DIP
joint
– None associated
injuries
– Ring finger most
commonly involved

18. Fractures of the Distal Phalanx
Treatment
• Jersey Finger
Classification
– Type I- vincula
ruptured with
tendon retracted to
the palm
– Primary repair
within 10 days
Able to fully flex PIP
joint

19. Fractures of the Distal Phalanx
Treatment
• Jersey Finger
Classification
– Type II- vincula intact
with tendon
retracted to level of
the PIP joint.
– Primary repair as
soon as possible.
Primary repair may
still be possible
several weeks
Unable to flex PIP
joint

20. Fractures of the Distal Phalanx
Treatment
• Jersey Finger
Classification
– Type III- Fracture
fragment retains
tendon at DIP joint
– Repair of fracture
fragment (6 weeks)

21. Fractures of the Distal Phalanx
Treatment
• Jersey Finger
Classification
– Type IV- Fracture
fragment has tendon
avulsed off and
retracted
– Repair of fracture
fragment and tendon
repair (12 weeks)

22. Fractures of the Distal Phalanx
Treatment
• Tourniquet high on arm, pre-operative
antibiotic
• Volar zigzag incision from just proximal to
PIP joint to just distal to DIP joint
• Expose flexor tendon sheath
• Transverse incision just distal to A2 pulley,
look for tendon
• If unable to locate tendon, make small
transverse incision just proximal to A1 (1cm)
pulley(at the level of the distal palmar
crease). Incise sheath proximal to A1 pulley,
pull tendon end into wound
• Place 3-0 Prolene stitch in tendon end

23. Fractures of the Distal Phalanx
Treatment
• Pass small catheter/suture passer from PIP joint incision into
palm through the flexor tendon sheath.
• Pull tendon into finger past A2 pulley (1.5-1.7cm)
• Pass tendon under A4 pulley (0.5-0.7cm) to its distal phalanx
insertion
• Prepare bone bed on distal phalanx. Be sure to preserve
palmar plate.
• Drill K-wire into distal phalangeal bone bed exiting through
the mid portion of the nail plate.
• Tie suture over a button on the top of the nail plate.
(alternative =suture anchor instead of bone tunnels and
button)
• Irrigate and then Close wounds
• Dorsal splint with wrist in slight flexion

24. 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.

25. Complications
• Malunion:
– Malrotation requiring rotational osteotomy
• Tendon adherence:
– Common, especially in crush injuries
• Nonunion:
– Rare, but more common with open than with closed
fractures
• Soft-tissue interposition
• Infections
• Stiffness:
– Immobilization for >3 weeks can result in permanent
loss of motion.

26. Paronychia
• Clean area with alcohol or
betadine
• Perform digital nerve
block
• Area of greatest
fluctuance
• Remove pus
• Debride nail if necessary
• Antibiotics
• Dressing

27. Paronychia

28. Felon
• Abscess of distal pulp
• Results from
penetrating trauma
• Bacteria trough eccine
sweat glands
• Pulp is tense and
tender
• Significant edema

29. Felon
• Fish-mouth incision
• Hockey-stick/ J-
incision
• Transverse palmar
incision

30. Thank you for your attention 

31. Failed treatment