Fractures of the proximal and middle phalanges of the hand
A basic distinction is made between fractures in the shaft area and in the area of the joints. In the shaft area, surgery is only
indicated if satisfactory reduction cannot be achieved after aligning the axes under conduction anaesthesia using a correct dynamic “intrinsic plus”
splinting arrangement. Intra-articular fractures, or fractures extending from the shaft into the joints,
must always be treated surgically.
Method:
Reduction is performed under fracture haematoma block anaesthesia. The malalignment is corrected by longitudinal traction, flexion at the metacarpophalangeal joint and rotational movements. The wrist is held in 30° of extension. The splint consists of a dorsopalmar plaster or synthetic splint and a double-layered tubular bandage divided into two by a seam for the injured and the adjacent finger, the so-called “finger gun”. The metacarpophalangeal joints are flexed to 70°–90°. In this “intrinsic plus” position, the extensor aponeurosis is tensioned and thus provides firm splinting of the fracture. This splinting arrangement is worn for four weeks until
the fracture has healed.
The aim of functional treatment of proximal phalanx fractures is to achieve bony healing and free mobility simultaneously rather than
one after the other. Active movement exercises of the middle and distal joints in an “intrinsic plus” splinting arrangement
prevent restricted movement and the subsequent occurrence of rotational and axial malalignment.
Follow-up examinations showed that very good results are achieved with oblique fractures, spiral fractures and transverse fractures. Bending fractures must be treated with particular care. Dorsally open angulation of up to 20° in the proximal third does not lead to any functional impairment. In particular, full extension at the PIP and DIP joints can also be achieved.
If malalignment of more than 20° cannot be reduced and maintained, a surgical procedure must be chosen.
Fractures in the distal third of the shaft in particular can rarely be reduced and maintained using this method.
In extension, correct rotation of the fingers can be checked by the planes of the nails.
In flexion, malrotation only becomes truly apparent. After reduction, axial malalignment of more than 20° in a plaster cast
or thermoplastic splint must not be tolerated.
Reduction of the fracture under longitudinal traction. If this is not successful (several fragments), reduction with reduction forceps over the plate.
– Spiral fractures without significant shortening can be reduced and maintained in the dynamic splinting arrangement.
– Spiral fractures extending into the joint must always be treated with osteosynthesis.
Spiral fractures in which reduction of the
rotational malalignment is unsuccessful indicate
interposition in the fracture gap and
must be reduced openly and treated with osteosynthesis.
Intra-articular (extending into the joint space) basal fracture of the proximal phalanx
Intra-articular fractures of the phalanges must always be treated surgically. A step-free reconstruction of the joints is required. These fractures are reduced under longitudinal traction and axial correction. The joint fragments often align through ligamentotaxis, or the joint-bearing parts must be manipulated openly. After reduction, which is performed with pointed clamps, the fragments are temporarily fixed with K-wires and finally a locking grid plate or T-plate is fitted.
Sources and further information
Further reading on Medizin Aktuell
