General treatment principles of phalangeal fractures

The most common problem following phalanx fractures is stiffness, and the best means to prevent this is early protected motion. Many factors contribute to stiffness. The internal wound from a proximal or middle phalanx fracture always breaches both flexor and extensor tendon surfaces, and tendon adhesions of both systems are the rule - even in non-displaced fractures. The combination of swelling and immobility alone frequently results in flexion contractures of the proximal interphalangeal joint and extension contractures of the metacarpophalangeal joint. These joints are always sprained or injured to some extent by the forces that produced the adjacent fracture. The proximal and distal interphalangeal joints may remain stiff, painful, and swollen for as long as a year after a closed injury - even without a fracture. Additionally, the finger extensor mechanism easily unbalanced by relatively small changes in phalangeal length from either shortening or angulation, leading to secondary joint contractures distal to the fracture.

The precision cascade of motion of the fingers may be grossly disrupted by minor degrees of phalangeal malunion, much more so than for other fractures. For these and other reasons, it is best to achieve anatomic reduction, stable fixation and begin early motion. A variety of external, percutaneous and open fixation techniques may be used. Plate and screw fixation systems for phalangeal fractures have become increasingly refined and popular, but adhesions produced by the necessary surgical exposure for open reduction may compound the tendency for stiffness. Fortunately, tubular hand bones heal rapidly, and in most cases fixation is required for no more than a month, allowing many fractures to be treated with percutaneous fixation. If gentle stress on the fracture site is painless, healing is probably strong enough to withstand unresisted active motion without fixation. For metacarpal and phalangeal fractures, this clinical evaluation is more important than radiographic evidence of healing.

In general, patients must begin moving their fingers before the x-ray shows solid bone bridging. For every finger fracture non-union, you will see a hundred stiff fingers.

Most patients are critically uninformed about problems with stiffness and about the frequently lengthy recovery period associated with phalangeal fractures ("it's just a finger"). During the initial interview, a blunt discussion by the examiner - demonstrating with their own hand what they mean by "stiffness" by making a fist and then straightening the other fingers while holding one finger fixed in partial flexion - is time well spent.

The management of hand fractures as with fractures elsewhere can be broken down into a simple decision tree, based on the injury, technically possible goals, and patient participation (Fig. 2).

Phalangeal fracture treatment
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