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Phalangeal Fractures

Practice Essentials

Hand injuries are very common in all sports, especially in ball-playing athletes. Most athletic hand injuries are closed hand injuries and include ligamentous injuries, fractures and fracture-dislocations, tendon injuries, and neurovascular problems. There is increasing recognition that fractures and dislocations of the hand can result in long-term pain and disability if they are not recognized and treated early.

Extra-articular fractures of the distal phalanx are common and are associated with significant soft-tissue injury. Most distal phalangeal fractures are crush injuries from a perpendicular force. They can be associated with significant debility, usually in the form of soft-tissue loss, nail bed injury, or posttraumatic neuromas. Intra-articular fractures of the distal phalanx can result from avulsion of either the extensor tendon, also known as mallet fractures, or of the flexor digitorum profundus, also known as jersey fractures. These can be associated with either small dorsal fragments or larger articular fragments with volar subluxation of the volar fragment. Conservative management is usually the standard of treatment.

Fractures of the proximal phalanx are more common than fractures of the middle phalanges. Dorsal or palmar angulation may occur with these fractures, depending on their location. Nondisplaced fractures are usually stable and are treated with closed reduction and fixation.
If significant comminution or segmental bone loss is present, these unstable fractures may require either internal or external fixation.

The proximal interphalangeal (PIP) joint is particularly vulnerable to injury as either an ligamentous or intra-articular fracture, with or without subluxation or dislocation. Middle phalangeal articular fractures at the PIP joint include dorsal lip fractures, palmar lip fractures, and central articular disruptions or pilon fractures. Avulsion and impaction sheer are 2 fracture mechanisms.

Middle phalanx palmar lip fractures are the most common form of osseous injury associated with PIP joint fracture-dislocations. Dorsal fracture-dislocation of the PIP joint is reported to occur in 9 of every 100,000 people each year. Many of these injuries are frequently ignored or treated inappropriately. As a result, there can be permanent swelling, pain, and variable degrees of stiffness, angulation, and degenerative changes.

If a serious phalangeal injury is suspected, radiographs should be performed before more forceful testing. Hand fractures in the athlete are treated with adequate alignment, immobilization, and then motion. In general, intra-articular fractures must be reduced anatomically. Reduction requires early recognition of the exact location of the fracture and having a complete understanding of the muscle pull on the fragments, then minimizing the deforming force.

See the image below.

Acute dorsal proximal interphalangeal joint fractu

Acute dorsal proximal interphalangeal joint fracture-dislocation.

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Finger, Broken Hand, and Wrist Injury.

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