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PROBLEM

The most common complication after proximalphalangeal fractures is proximal interphalangeal (PIP)joint extensor lag.1 Phalangeal fractures are among themost challenging injuries that hand surgeons andtherapists treat. Although initial injury severity is themost highly correlated determinant of hand fractureoutcome, occurrence adjacent to the flexor tendonsheath notoriously accentuates the ultimate risk ofstiffness at every level of injury severity, similar toflexor tendon lacerations in the same area.2–5 In addi-tion to complex wounding, intra-articular fractureinvolvement, comminution, bone loss, and multiplehand fractures may compound the problem furtherand increase the risk of digital stiffness.

CAUSE OF THE PROBLEM

There are two major causes of PIP joint extensor lag:soft tissue adhesions and persistent skeletal deformi-ty. Fracture hematoma permeates the zone of injury.The injury soon incites a proliferative fibroblasticresponse of the multiple surrounding collagenousstructures that is proportionate to injury severity. Scartissue tends to involve all of the structures within thezone of injury (“one wound–one scar”).6 The resulting

scar tends to produce adherence between the boneand the adjacent tendons, joint capsule, and liga-ments, especially when the tendons remain dormantduring fracture healing (Figure 1). Adhesions formedbetween the extensor mechanism and the fracturemay result in loss of extensor glide.7 Simple fracturescaused by low-energy injuries occasionally may becomplicated by some measure of permanent stiffnessas a result of this process. When adjacent flexor orextensor tendon injury accompanies a proximal pha-langeal fracture, the difficulty of treatment andachieving a favorable outcome may be compoundedsubstantially. Surgical treatment requires a second“planned injury,” superimposing further soft tissueinjury and increasing the risk of soft tissue adhesions.

Persistent fracture deformity may contribute to theproblem. Fractures of the proximal phalangeal shafttypically exhibit an apex palmar angulation with thefracture gap wider volarly and compressed dorsally.The intrinsic muscles flex the proximal fragment,whereas the distal fragment is extended by theattachment of the central slip to the dorsal lip of themiddle phalanx. The axis of rotation of proximal pha-langeal fractures lies on the fibro-osseous border ofthe flexor tendon sheath. The moment arm from therotational axis of the fracture site to the extensor ten-don is greater than that between the axis and the flex-or tendons, further contributing to apex palmarangulation. If volar angulation is >15°, the dorsalgliding surface of the proximal phalanx (P1) is short-ened relative to the length of the extensor mecha-nism.8 As palmar angulation incrementally shortens

Alan E. Freeland, MDDepartment of Orthopaedic Surgery and RehabilitationUniversity of Mississippi Medical CenterJackson, Mississippi

Maureen A. Hardy, PT, MS, CHTHand Management CenterSt. Dominic HospitalJackson, Mississippi

Shannon Singletary, PT, ATC, CSCSSports Medicine ServiceDepartment of Orthopaedic Surgery and RehabilitationUniversity of Mississippi Medical CenterJackson, Mississippi

ABSTRACT: Proximal phalangeal fracture stability is crucial forthe initiation of early and effective exercises designed to recoverdigital and especially proximal interphalangeal joint motion.Active digital flexion and extension exercises are implemented bysynergistic wrist motion. Joint blocking exercises and active ten-don gliding exercises in protective blocking splints are instrumen-tal elements of early treatment. Dynamic splinting and serial fin-ger casting are used in recalcitrant, severe, and late presentingcases. Surgical release is a last resort in regaining proximal inter-phalangeal joint motion. This measure is reserved for a failure oftreatment when residual proximal interphalangeal joint contrac-ture is persistent and severe enough to cause serious impairmentof digital motion and hand function.J HAND THER. 2003;16:129–142.

Rehabilitation for Proximal PhalangealFractures

April–June 2003 129

Correspondence and reprint requests to: Alan E. Freeland, MD,Department of Orthopaedic Surgery and Rehabilitation,University of Mississippi Medical Center, 2500 North State Street,Jackson, MS 39216; e-mail: <[email protected]>.

the fractured proximal phalangeal, the extensormechanism may have 2 to 6 mm of reserve owing toviscoelastic adaptive properties before the sagittalbands tighten to produce a progressive extensor lagat the PIP joint (an average of 12° for every mm ofbone–tendon discrepancy).2,9 The redundant extensormechanism becomes too lax to complete terminal PIPjoint extension. Because the extensor mechanism hassmall excursions, even loose adhesions may have asignificant adverse effect on finger function.10

Phalangeal shortening resulting from bone compres-sion, loss, or comminution may accentuate this prob-lem further. Persistent volar angulation of >25° alsoprogressively limits finger flexion.11 Oblique frac-tures may cause digital rotation in addition to theaforementioned deformities. Overlapping or obstruc-tion of the adjacent fingers may occur with flexion. Apalmar fracture spike may block adjacent joint flex-ion. The extensor lag soon develops into a fixed jointcontracture, resulting in a worst-case scenario of ajoint that has lost extension and flexion.12–14 Apseudoclaw deformity develops, and further jointcontracture may follow.

EVALUATION

History

A thorough account of the circumstances of theinjury and a physical examination targeted at thehand are important in establishing the cause andmechanism of the fracture and the likelihood of otherinjuries. A careful history also clarifies significant per-sonal, social, and demographic data, such as the age,dominant hand, personal responsibilities, recreationalpreferences, and occupational status of the patient. Itis important to establish the patient’s dependence onothers for activities of daily living or survival.

Physical Examination

Examination of the hand should identify the area ofmaximal tenderness; the location, type, and severity

of any deformities or wounds; the functional status ofall flexor and extensor tendons; and the neurovascu-lar status to the extent that the patient’s conditionwill allow. Angular, rotational, and shortening defor-mities should be catalogued with regard to directionand extent clinically and radiographically. Digital orwrist block anesthesia may be helpful in the staticand dynamic assessment of fracture stability, digitalmotion, and deformity and in determining whetherthere is any impingement of the injured digit onanother during motion.

Imaging Studies

Standard x-rays usually are sufficient for evaluationof phalangeal shaft fractures and should includeanteroposterior or posteroanterior and lateral viewsof the involved digit. A true lateral view is especiallyimportant in accessing articular fractures and angu-lation in the sagittal plane. Additional oblique viewsmay be helpful in defining fracture configuration,displacement, deformity, fragment relationships, andintra-articular fracture extension.

TREATMENT

Successful treatment of proximal phalangeal frac-tures, the prevention of restrictive adhesions, and afavorable outcome are based on achieving stableanatomic (or near-anatomic) position of the fracturethat either is inherently stable or is supported by fix-ation and an early controlled motion program thatfocuses on tendon gliding and joint mobility.10,15–17

Stable fractures do not displace spontaneously orwith active range-of-motion (ROM) exercises.17

Fracture stability is instrumental in pain control andfunctional recovery. Fixation, when necessary, shouldbe performed with as little additional trauma as pos-sible to avoid unnecessarily compounding the injury.The ideal goal of treatment is a well-aligned, pain-free, stable, mobile digit with good sensation andgood circulation that participates in unrestrictedhand function. The axiom “anatomy now, functionlater” is inconsistent with a successful outcome.2 Itmakes no sense to fix a fracture and not move it. Lossof tendon gliding of the extensor mechanism over theproximal phalanx is almost always irretrievable.Early digital motion is essential.

Despite the difficulty of achieving this goal, thebest opportunity lies with a combined effort betweenthe patient, hand surgeon, and hand therapist. Thehand surgeon and therapist must communicate withand even inspire the patient. The patient mustembrace enthusiastically and comply with the reha-bilitation program.

Because surgery represents a second and addition-al injury, operative treatment must be selected pru-dently. The principle of minimizing operative trauma

130 JOURNAL OF HAND THERAPY

FIGURE 1. Extensor tendon adhesions (arrow 1), flexor tendonadhesions (arrow 2), or both may form adjacent to a proximalphalanx fracture.

when applying internal fixation is essential for suc-cessful operative intervention. Nevertheless, pha-langeal fractures that require open reduction andfractures that are open owing to injury, especiallythose with complex wounds, comminution, or boneloss, require secure (and often even mini-plate) fixa-tion for any chance of successful repair or reconstruc-tion and rehabilitation.

The surgeon must assess the variables and formu-late the treatment plan that he or she believes wouldsuit best a particular fracture (and patient) situation.There may be more than one method that would pro-vide comparable results. In these instances, judgment,the surgeon’s training and experience, and availableresources may enter into the decision-making process.The method, implant, or implant configuration cho-sen may be less important than treatment supervi-sion, patient compliance, and adherence to the afore-mentioned principles of fracture management.

The need for biomechanical stability must be bal-anced with the need to preserve biologic integrityand blood supply, while minimizing the risk of scar-ring. In each instance, there is no substitute for arm-ing the physician with the facts while allowing himor her to select the methods that correlate best withhis or her skills and with the patient’s unique cir-cumstances. Hand fracture treatment is a combina-tion of science and the art of its application.

CLOSED FRACTURES

Nondisplaced Fractures

Most closed simple phalangeal shaft fractures areundisplaced or minimally displaced and tend to bestable.12,18–21 This inherent stability is due to configu-ration (transverse or short oblique), sufficientperiosteal support, or both.

Buddy taping or splinting to an adjacent unin-volved finger may be sufficient treatment for stableundisplaced or minimally displaced simple trans-verse or nearly transverse phalangeal shaft fracturesin a compliant patient.12,18–21 Alternatively a statichand-based or short arm splint may be applied forpatients if the physician believes that they mayrequire more protection or support. Patients withundisplaced simple fractures of unstable oblique con-figuration, such as unicondylar or oblique diaphysealphalangeal fractures, may be treated more safely withstatic splinting during the initial 4 weeks of treatment.These fractures may not displace spontaneously in astatic splint but may collapse with rigorous motionbefore the appearance of fracture callus on x-ray.

When at rest or immobilized, fingers should bepositioned functionally so that the metacarpopha-langeal (MCP) joints are supported at 50° to 70° offlexion and the PIP joints are supported at 0° to 15° offlexion to minimize the risk of joint contracture.

These positions also allow relaxation of the intrinsicmuscles, facilitating balance at the fracture site. Earlyprogressive active ROM exercises are delayed 3 to 4weeks only in patients treated with static splints; theymay be initiated at any time in patients treated withbuddy splints. Simple phalangeal fractures treatednonoperatively usually may be presumed sufficient-ly healed to initiate gentle (not exceeding thepatient’s pain tolerance) progressive active ROMexercises ≤4 weeks after injury. The x-ray appearanceof fracture callus further verifies this presumption.Normally, fracture callus calcification begins 10 to 21days after injury. There may be a little delay beyondthat time in the x-ray appearance of phalangeal frac-ture callus, but rehabilitation may proceed rigorous-ly when it is seen.

Dynamic functional splinting may be selected forany anatomically positioned simple fracture of stableconfiguration (transverse or nearly transverse) or ofunstable configuration (oblique) that is stable byvirtue of spanning fracture callus as visible on x-ray.Functional positioning permits immediate activeflexion of the interphalangeal joints and enables theextensor mechanism to act as a tension band over theproximal phalanx.12,22,23 Active motion simultaneous-ly compresses the fracture and stimulates periostealcallus formation and initiates the recovery of digitalmotion. The fracture should be monitored serially byx-ray for position, alignment, and healing in each ofthese treatment methods.

Displaced Fractures

A minimally displaced fracture has displacementwithin one or more of these x-ray parameters: <15° ofpalmar angulation in the sagittal plane, <10° of angu-lation in the coronal plane, <4 mm of shortening, and<5° of rotation. Although phalangeal fractures havesome tolerance for shortening, loss of rotationalalignment quickly translates into unacceptable defor-mity. Additionally, the finger must flex to within 1 cmof the distal palmar crease and have ≤30° extensorlag, and it must not impinge on or overlap an adja-cent finger during digital flexion. These guidelinesshould be considered as approximate rather thanabsolute because there are individual exceptions,extenuating circumstances, or individual patientrequirements in some cases. A digital block with localanesthesia may help the physician to determinewhich patients meet these criteria. Patients who meetthese criteria and whose fractures are stable eitherbefore or after manipulation may be treated by closedmethods and without fixation, similar to patientswith stable undisplaced fractures, at the discretion ofthe responsible physician.

If a simple proximal phalangeal shaft fracture ofstable configuration (transverse or short oblique) hasonly a palmar angular deformity, there is usually an


intact periosteal hinge dorsally opposite the angula-tion. Manipulative reduction is usually successful.The fracture may be treated similarly to its undis-placed or minimally displaced counterpart. Kirschnerwire (K-wire) splinting may be added to ensure a sta-ble reduction during early fracture healing.

Surgical Management

Indications

When phalangeal shaft fractures are intrinsicallyunstable or require open reduction or when deformityrecurs after an initial closed reduction withoutimplants, fixation is indicated. Displaced oblique andcomminuted fractures are unstable owing to their con-figuration and periosteal disruption. Periosteal disrup-tion and the resulting instability often correlate withthe amount of fracture displacement. Bone loss alsocauses instability. Internal fixation may also be prefer-able to external splinting in patients with polytrauma,patients with systemic impairment, or older patientsto avoid a cumbersome splint, cast, or dressing.

Reduction should be established and maintainedby combining the most reliable and least intrusivetechniques appropriate to the situation. Stabilityneed not be rigid and it does not require employmentof the strongest of available fixation choices. The fix-ation method or implant selected need only providea threshold level of strength that reliably holds thefracture securely until it has healed sufficiently sothat it is no longer implant-dependent and wouldallow simultaneous early rehabilitation.

Surgical incision, especially when accompanied byperiosteal elevation and particularly in the zone ofthe flexor tendon sheath, risks additional scar forma-tion and fracture fragment devascularization. Thephysician must weigh the potential benefit of theincreased biomechanical stability of the fracturegained through surgical incision against the addi-tional risk of consequent digital stiffness and delayedhealing. This may be especially true of late presentingdisplaced fractures that are stable and show callusformation on x-ray but are pain-free and functionaldespite mild and functionally nonobstructive defor-mity. Operative treatment to achieve an improved ormore perfect reduction in these instances risks a dou-ble dose of soft tissue damage that may result in dig-ital stiffness and a poorer outcome than that achievedby accepting the initial presentation and the milddeformity and impairment. It is a shallow accom-plishment to have an anatomically aligned fractureon x-ray and a stiff finger.

Closed Reduction and Internal Fixation

Most unstable displaced simple phalangeal shaftfractures may be treated successfully by transcuta-neous K-wire insertion.18,19,24,25 Wires splint but donot compress fractures. K-wires temporarily maytransfix the adjacent extensor mechanism to the bone,but permanent problems are rare if the wires areremoved within 4 weeks after application. Similarly,pin irritation, infection, and migration seldom causepersistent problems within this short interval.

One or more intramedullary wires act as internalreduction splints and reliably support transverse orshort oblique fractures. In fractures of the proximalportion of the phalangeal shaft, transcutaneous K-wires may be inserted from proximal to distal formore secure fixation of the smaller proximal fragmentto the main body of the phalanx. Conversely, in frac-tures of the distal portion of the phalangeal shaft, thewires may be inserted from distal to proximal. Thislatter technique also protects the proximal phalangealgrowth plate in children. In the mid portion of thephalanx, either technique may be used (Figure 2).

If closed displaced simple oblique fractures can bemanipulated into a reduced position, they may bestabilized by percutaneous transfixation pinning(Figure 3). Percutaneous mini-screw fixation is anoth-


FIGURE 2. A closed displaced unstable transverse midshaftproximal phalanx fracture is treated with closed reduction andtranscutaneous retrograde intramedullary Kirschner wires.

er alternative.26 Mini-screws are simply K-wires thathave threads on their core to purchase the distal frac-ture fragment and a head to buttress the proximalfragment. They compress the fracture and are moresecure than K-wire fixation, but they may be techni-cally more difficult to apply. Mini-screws may beexchanged for K-wires in long oblique and intraartic-ular fractures. Concentric K-wire and mini-screwdiameters facilitate this exchange. A 0.045-inch (1.1-mm) diameter K-wire is the same diameter as thescrew core of the 1.5-mm thread diameter mini screw.A 0.062-inch (1.5-mm) diameter K-wire is the samediameter as the screw core of the 2.0mm thread diam-eter mini screw. Removal of the K-wire, drilling theproximal cortex to the mini-screw thread diameter,and insertion of the appropriate size self-tappingmini-screw achieve a stable compression mini-lagscrew fixation.15–17

Internal Fixation

Incisions and Approaches. Phalangeal shaft fracturestraditionally have been approached through a dorsalskin incision.27 The extensor apparatus may be divid-ed in the midline. O’Brien28 approached the proximalphalanx between the central and lateral bands in anadditional effort to preserve the lateral band and itsfunction. A midaxial incision allows implant applica-tion to the lateral side of the fractured phalanx.29,30

This approach decreases the risk of adhesions andirritation under the extensor apparatus and obviatesdigital impingement between a dorsally applied miniplate and the extensor apparatus that often physical-ly restricts the extremes of finger flexion and exten-sion. The lateral band may be excised to improveexposure, prevent irritation between the implant andthe lateral band during motion, and minimize scar-ring further.31 Distally a midaxial approach andimplant application minimizes the risk of operativeinjury to the central slip and consequent boutonnieredeformity. A distally based flap that divides the cen-tral slip proximally to the PIP joint allows access tocondylar fractures.32

Kirschner Wire Fixation. K-wire configurations havebeen described. Pins may be inserted transcuta-neously as previously described after open fracturereduction or crossed retrograde through the intra-medullary canal of one fragment preceding reduc-tion. When the latter technique is used, the fracture isreduced and the pins are driven across the fracture tocomplete the fixation.33 The wires should cross eitherproximal or distal to the fracture site to avoid fracturedistraction. This technique is particularly effective inthe absence of x-ray capabilities.14

Mini-Screw Fixation. In the clinical setting, mini-screws have been shown to provide stable fracture fix-ation and little interference with tendon gliding.34–41

They may be used in unstable or potentially unstable

oblique fractures of the phalangeal shafts and forintra-articular fractures (Figure 4). Oblique shaft frac-tures should be twice the adjacent bone diameter sothat at least two screws may be inserted. Self-tappingdesign facilitates mini-screw application.42

Mini Plates. Mini plates may be used selectively onphalanges.34,35,38–40,43 44 They may be a good choice inclosed transverse or short oblique fractures thatrequire open reduction, open fractures, replantations,and the multiply fractured hand. Mini-plates areespecially useful in fractures with comminution orbone loss. Straight mini-plates may be used for mid-diaphyseal fractures. (Figure 5) Mini-condylar platesare most suitable for periarticular fractures (Figure 6).The laterally applied mini-condylar plate stronglyresists the apex volar angulatory forces occurring inproximal phalangeal fractures.45

Mini External Fixation. Many surgeons advocate thetreatment of unstable phalangeal fractures with mini-external fixation.46–52 Simple mini-external fixatorsmay be used to stabilize unstable simple closed frac-tures. Static external fixation offers particular advan-tages in the treatment of open phalangeal shaft frac-tures with severe wounds, comminution, and bone


FIGURE 3. A closed oblique proximal phalanx fracture of unsta-ble configuration is treated with closed reduction and transcuta-neous transfixation Kirschner wires. This treatment allows earli-er and more intensive rehabilitation.

loss.53,54 Static mini-external fixators have been espe-cially helpful in the initial and provisional fixation ofsevere open hand fractures with significant bone andsoft tissue destruction. They may be maintained fordefinitive fracture management or replaced by inter-nal fixation, usually mini-plates, at the time of bonegrafting and wound closure or coverage.

The refinement of mini external fixators allows sta-bilization of phalangeal fractures, while permitting arelatively uninhibited ROM of adjacent digits. Thepins are inserted dorsolaterally between the extensortendon and lateral band whenever possible, and theextensor mechanism may be incised longitudinallyfor a short distance on either side of each pin to avoidtenodesis of the extensor mechanism to the adjacentphalanx. Ideally, there should be a minimum of twopins on either side of the fracture. Each pin shouldengage two cortices whenever possible. Adjunctiveindependent supplementary K-wire insertion may beused (Figure 7).

The advantages of the mini-external fixator in fin-ger fractures include minimal or no surgical exposureof the fracture site, adequate stability, and the abilityto manipulate an inadequately reduced or secondari-ly displaced fracture. Because transfixion of part ofthe extensor mechanism is often unavoidable in theproximal phalanx, functional results of external fixa-tion at the phalangeal level are less reliable than whenmini-external fixators are used at the metacarpal level.

OPEN FRACTURES

Open fractures present dual problems: the fractureand the wound.3,15–17,55–58 Fractures must be stabilizedusing the principles outlined earlier. The woundmust be cleaned, and then closed or covered. Woundcleanliness is the critical determinant of treatment.Simple wounds usually may be rendered surgicallyclean, and simple fractures may be fixed definitivelyat the time of initial surgery. Wound closure may becarried out simultaneously.

Complex wounds may require a “second look” toensure cleanliness at 48 to 72 hours after initial surgerybefore proceeding with reconstruction. Open fracturesmay require extension of the wound by incision toapply adequate fixation. Bone defects may be filledwith bone graft or bone graft substitute. When openfracture reduction and secure internal fixation arerequired, repaired digits are capable of and requiremore accelerated and intense mobilization to optimizefunctional recovery. Secure fixation and early motionmay help to reduce the risk of joint contractures andtendon adhesions in these severe injuries.

Low-energy gunshot injuries to the hand oftenresult in significant comminution or bone loss. Softtissue damage is generally limited, however, espe-cially when compared with severe crush or high-energy bullet injuries. Primary closure of the surgi-


FIGURE 4. A closed, slightly displaced unstable intra-articularfracture at the base of the proximal phalanx is treated with closedreduction and percutaneous mini-screw fixation.

FIGURE 5. A closed displaced unstable transverse midshaftproximal phalanx fracture could not be reduced satisfactorily byclosed manipulation. It was treated by open reduction through adorsal incision and dorsal mini-plate fixation.

cally clean wounds, internal fixation, and autogenousbone grafting do not appreciably increase the inci-dence of infection.55,59 Stable fixation allows the initi-ation of early active digital motion.

Bone Grafting

Cancellous bone may be used for incomplete bonedefects and for complete bone defects of approxi-mately 1.5 cm. The ipsilateral distal radius is an excel-lent donor source. Cancellous bone may be compact-ed in a small syringe with a plunger, then tapped outwith a long spinal needle. Compressing cancellousbone increases its structural integrity, may providemore potentially viable bone-generating cells perunit volume, and may help to ensure timely bonehealing. Intercalated corticocancellous bone grafts areused for larger defects. Bone carpentry techniques,such as dowels and sockets and mortising, are usedto enhance stability and healing at the fracture-bonegraft interfaces.55,60

REHABILITATION

The purpose of phalangeal fracture treatment is toachieve stable anatomic (or near-anatomic) position

that controls pain and allows early progressive reha-bilitation to proceed commensurate with the patient’stolerance (Figure 8). Protective functional positionalsplinting is maintained at rest, and blocking and ten-don gliding exercises and synergistic wrist and digi-tal exercises are an integral part of the recovery pro-gram. Dynamic splinting and serial casting may beused in instances when active exercises are insuffi-cient in recovering digital motion.

The recovery of digital motion may be the mostimportant determinant of final functional outcomein all hand fractures. Theoretically, because there areno fibroblasts in a closed injury or wound for 48hours and no fibrin of any strength for 4 to 5 days,this inflammatory period should be respected withimmobilization and edema control measures.Edema draws tissues into predictable patterns ofdeformity. Distended joint nociceptors, throughselective facilitation or inhibition of muscles, causesthe joint to rest in its most comfortable position, onethat accommodates the most volume of effusion.61

At the PIP joint, this is achieved at 30° to 40° of flex-ion. Unless edema and joint positioning are con-trolled, this posture of joint comfort becomes fixedand contracted (Figure 9).


FIGURE 6. A closed displaced unstable transverse fracture of thedistal diaphysis of the proximal phalanx could not be reduced byclosed manipulation. It was treated by open reduction through amidaxial incision and lateral application of a mini-condylar plate.

FIGURE 7. A closed displaced unstable oblique fracture of thediaphysis of the proximal phalanx required open reduction. Itwas treated with a mini-external fixator and an ancillaryKirschner wire. The mini-external fixator does not cross theproximal interphalangeal joint or limit its motion.

Functional Positional Splinting

Positioning of the hand after injury may be used toassist in biasing tension from strong to weak soft tis-sues. Casts or removable splints have the goal of frac-ture protection yet allow the controlled motion neces-sary for tendon gliding. Radial or ulnar gutter splintsthat totally immobilize the digit and encase the PIPjoint are indicated only for displaced fractures thatremain unstable after closed reduction (Figure 10).64

Functional splinting has been recommended for sta-ble fracture reduction with or without internal fixa-tion to prevent joint contractures and ensure compli-ance with the postoperative exercise regimen.8,23,65,66

Positional training splints are worn continuously for 3weeks for stable undisplaced or minimally displacedfractures and thereafter as a removable exercise splint(Figure 11). Inclusion of adjacent noninjured fingers inthe cast or splint, buddy taped to the fractured finger,may help to protect the injured finger and controlangulation and rotation.

Functional positional splinting with the wristplaced in slight flexion increases tension in the exten-sor mechanism and simultaneously relaxes flexor ten-don tension.12,22,67 A short arm splint is used initially(Figure 12), which can be reduced serially to a handbased splint (Figure 13). Positioning the MCP joint inflexion with a dorsal block has several advantages:

• The extensor hood moves distally with MPJ flexionproviding circumferential compression to theproximal phalangeal fracture.

• Hyperextension at the MPJ with proximal extensortendon glide is prevented.

• Extensor tendon tension is focused at the PIP joint.• In MCP jointflexion, the flexor tendons rest farther

away from the proximal phalangeal fracturesite.68,69


FIGURE 8. All methods of proximal pha-langeal fracture treatment are designed to pro-vide reliable fracture stability so that earlyrehabilitation may be initiated safely. Themore stable the fracture, the more quickly andintensely the rehabilitation may proceed with-in the patient’s individual tolerance.

FIGURE 9. Extension lag after open treatment of a phalangealfracture.

FIGURE 10. A splint immobilizing the proximal interpha-langeal joint should be used only for unstable proximal pha-langeal fractures that are reduced, unstable, and not internallyfixed.

KIRSCHNEROR

OTHER WIRETREATMENT

STATICPROTECTIVESPLINTING

FUNCTIONALPOSITIONALSPLINTING

If the patient has difficulty recovering or maintain-ing full passive PIP joint extension after the initial 3weeks of functional positioning splinting, specificPIP joint extension splints can be applied to achievefull joint mobility (Figures 14 and 15). Dial-out exten-sion splints (Figure 16) or serial casting (Figure 17) isindicated for severe or established joint contractures.Alternatively, if the patient has difficulty achievingfull PIP joint flexion, static splints that block MCPjoint flexion allow the full force of digital flexion to betransmitted to recover PIP joint flexion (Figure 18).

Tendon Gliding

Tendon gliding exercises are performed to glide thetendons differentially, reestablish joint motion, andprevent restrictive adhesions overlying the fracture(Figure 19). Digital flexor and extensor excursion of 5mm, or PIP joint motion of 0° to 40°, achieved duringthe initial 4 weeks after injury or operation minimizesthe risk of serious tendon adhesions and is a favor-able prognostic sign.70,71 These gliding exercises areinitiated at the first therapy session within the posi-tional splint and later are reinforced and continuedwhen splinting is discontinued.

Extensor Tendon Gliding Exercises

The central slip and lateral bands work in concertto extend the PIP joint. Micks and Reswick72 reported


FIGURE 11. A short arm protective splint with functional wristextension and a dorsal metacarpophalangeal joint block. FIGURE 12. A and B, A short arm protective splint with the

wrist placed in slight flexion and a metacarpophalangeal jointblock to maximize proximal interphalangeal joint active exten-sion. C, A volar component may be added at rest or at night tomaintain interphalangeal joint extension.

FIGURE 13. A hand-based protective splint with a metacar-pophalangeal joint block.

a differential action between the two. They foundthat the central tendon initiates extension with thePIP joint fully flexed, whereas the lateral bands con-tribute more as the PIP joint approaches full exten-sion. The lateral bands are responsible for terminalPIP joint extension.

The normal finger extensor mechanism requires 20mm of glide for full digital motion69; 14 mm occurs atthe MCP joint and 6 mm at the PIP joint. In theory, thedistal interphalangeal joint requires an additional 4

mm of excursion; however, the normal volar move-ment of the lateral bands during finger flexion obvi-ates this requirement. Adhesions formed between theextensor mechanism and the fracture result in loss ofextensor glide.7 Because the extensor mechanism


FIGURE 14. A finger-based dynamic proximal interphalangealjoint extension splint.

FIGURE 15. A dynamic extension assist splint that may be usedfor initial or early proximal phalangeal fracture rehabilitationand is especially useful for early proximal interphalangeal jointflexion contractures.

FIGURE 16. A dial-out dynamic extension splint.

FIGURE 17. Serial casting for proximal interphalangeal jointflexion contractures.

over the proximal phalanx has such a small excur-sion, even loose adhesions have a significant effect onfinger function.10

Evans and Thompson71reported on the sequence ofevents causing extensor tendon adhesions over theproximal phalanx after central slip injuries, whichcan be extrapolated to describe the same problemafter proximal phalangeal fracture. The entire 20 mmof extensor glide occurs at the MCP joint alone,resulting in a gradual MCP joint hyperextension. Apseudo-claw deformity of the finger occurs when thePIP joint extensor lag accompanies MCP joint hyper-extension (Figure 20).Therapeutic attempts to stretchthe PIP joint into flexion only serve to attenuate thecentral slip distal to the site of its adherence to thebone. Although flexion may improve with centralslip attenuation, the extensor lag remains.

The functional positioning splint prevents MCPjoint hyperextension and directs extensor tension dis-tally to the PIP joint. While in the splint, the distal PIPjoint extension strap is released for gliding exercises,and the patient relaxes the PIP joint into flexion. Theemphasis initially is on full 0° active extension withprogressive PIP flexion as the starting point. Evansand Thompson71 state that achieving 4 mm of earlyextensor tendon glide prevents adherence and exten-sor lag. The patient must be monitored to preventsubstitution for extensor glide by instead actively

flexing the PIP joint and allowing it to relax back intosemiextension.

Later when out of the cast, active digital flexion andextension exercises are implemented by synergisticwrist motion, and the patient is instructed to blockmanually the MCP joint from full extension and slight-ly flex the wrist while performing PIP joint extensionexercises (Figure 21). Functional electrical stimulation,using dual stimulation of extensor digitorum commu-nis and the intrinsics, can be used to facilitate correctmuscle action for full PIP joint extension.

Flexor Tendon Gliding Exercises

Both flexor tendons, the flexor digitorum profun-dus proximally where it lies along the proximal pha-lanx and the flexor digitorum superficialis distally asit divides into two insertions that wrap around theprofundus, can become adherent to the fracture cal-lus.8 Within the functional positioning splint, blockingexercises can be performed to activate flexor digito-rum profundus and flexor digitorum superficialis andFDS gliding across the fracture site. Composite fistedflexion is gained as PIP joint mobility improves.

When splints are removed, synergistic wrist andfinger exercises can be initiated. Patients are instruct-ed simultaneously to extend the wrist while flexingthe fingers then flex the wrist while extending the fin-gers (see Figure 20). The full range of each repetitiveactive exercise cycle consists of first extending the


FIGURE 18. A, Reverse angle showing proximal interpha-langeal joint stiffness. B and C, A static metacarpophalangealjoint blocking splint allows all of the forces of digital flexion to betransmitted to the proximal interphalangeal joints.

FIGURE 19. The three key blocking exercises.

wrist and making a fist, then flexing the wrist to cre-ate a digital tenodesis effect while forcefully straight-ening the fingers. This technique has been shown toapply low load with high excursion for tendons.73–75

When fingers move synchronously together towardfull flexion or extension, the tethering quadriga effectof the common profundus muscle to the middle, ringand small finger profundus tendons is eliminated,and the digits may move to gain greater force andpower.76

Strengthening and conditioning exercises arephased gently and progressively into the rehabilita-tion program beginning at 6 weeks after fracture,depending on the adequacy of healing as judged byclinical and x-ray evaluation. Bone remodeling inresponse to stress is not predicated on the method offixation. Fractures treated by either closed or rigidmethods of fixation must be protected from excessivestresses initially during the inflammatory and repairstages. Although rigid fixation methods allow forearlier, unprotected motion, they do not acceleratethe fracture repair process. During the remodelingphase, progressive loading of the fracture assists incallus conversion to bone and strength developmentin primary bone healing.

CONCLUSION

Most phalangeal shaft fractures are closed, eitherundisplaced or minimally displaced, and stable.They may be treated nonoperatively and with sup-portive and symptomatic treatment. When necessary,phalangeal shaft fracture fixation needs only to bestrong enough to immobilize the fracture until thestrength of the healing callus surpasses that of the fix-ation. Generally, this takes about 4 to 6 weeks foruncomplicated simple hand fractures and longer forcomminuted fractures and fractures with complexwounds, including those in which there is bone lossthat requires bone grafting. The selected implant alsoshould be able to withstand the rigors of early digitalmotion. The decision of whether or not to open and

consequently to devascularize the fracture andpotentially expose the adjacent moving and glidingstructures to restrictive scarring is of equal or moreimportance than that of implant selection and config-uration. The additional stability provided by theimplant must offset the risks of operative dissection.

Early postfracture controlled motion programsfocus on hand positioning and tendon gliding as thebest measures in preventing the pseudo-claw defor-mity common to proximal phalangeal fractures.Functional positional splint techniques are used toprovide soft tissue tension compression to the frac-ture site, protect the healing fracture from excessivestresses, direct contractile forces to distal joints, andprevent joint deformities. Specific differential tendongliding exercises are performed for the extensors(central slip and lateral bands) and for the flexors(flexor digitorum superficialis and flexor digitorumprofundus). Synergistic wrist motion may be used tobias tension in the desired direction of digital motion.This therapy regimen seeks to balance the require-ments for preservation of fracture stability, whileachieving soft tissue mobility through a program ofprogressive and controlled digital motion.


FIGURE 20. A pseudoclaw finger.

FIGURE 21. A, Synergistic synchronous wrist extension andfinger flexion. B, Synergistic synchronous wrist flexion and fin-ger extension. C, Manual metacarpophalangeal joint blockingexercises maximizing extrinsic extension at the proximal inter-phalangeal joints.

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