Distal phalanx fracture

Naranjargalan,.MDNovember 2, 2015

20th presentation

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.

Fractures of the Distal Phalanx• Anatomy– Extensor and

flexor tendons insert into the base of the distal phalanx

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)

Fractures of the Distal PhalanxClassification

• 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

• Salter-Harris

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

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.

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

Fractures of the Distal Phalanx Treatment• DIP Dislocation• AP, lateral + oblique

view of affected finger.Mallet finger

Fractures of the Distal Phalanx Treatment

• Mallet Finger Classification1. Closed No fracture(full extension or hyperextension in the DIP joint)

• Maintain for 8weeks, followed by nightime splint use for 2-3 weeks.

Fractures of the Distal Phalanx Treatment

• Mallet Finger Classification2. Open = lacerations

• repaired with running suture

Fractures of the Distal Phalanx Treatment

• Mallet Finger Classification3. 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.

• K-wire

Incisions

• Dorsal to the DIP joint incision

• Dorsal to IP joint of the thumb incision

Fractures of the Distal Phalanx• Jersey finger (Flexor

Tendon Avulsion)Anatomy– Flexor digitorum

profundus tendon inserts into the base of the distal phalanx

Fractures of the Distal Phalanx

• Mechanism of Injury– Hyperextension

against a flexed DIP joint

– None associated injuries

– Ring finger most commonly involved

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

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

Fractures of the Distal Phalanx Treatment

• Jersey Finger Classification– Type III- Fracture

fragment retains tendon at DIP joint

– Repair of fracture fragment (6 weeks)

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)

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

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

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.

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.

Paronychia

• Clean area with alcohol or betadine

• Perform digital nerve block

• Area of greatest fluctuance

• Remove pus• Debride nail if necessary• Antibiotics• Dressing

Paronychia

Felon

• Abscess of distal pulp• Results from

penetrating trauma• Bacteria trough eccine

sweat glands• Pulp is tense and

tender• Significant edema

Felon

• Fish-mouth incision• Hockey-stick/ J-

incision• Transverse palmar

incision

Thank you for your attention

Failed treatment