Fracture Handbook

  

2. Proximal Phalanx

2.1. Proximal Phalanx Base (not involving the joint)
These are typically transverse i.e. straight across the bone in adults and through the growing part of the bone in children.


(A) Adults
This typically follows a fall with the finger tipping back most often affecting the little finger. Strapping down of the injured finger for 3-4 weeks seems to give good results. If this does not work then the break is wired along the line of the finger. The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.

When more than one finger is involved it can be particularly difficult correct the alignment with strapping. We almost always treat these with wiring.

(B) Children
Children usually come up with their finger bent out to the side. In particular the little finger bent out away from the hand. They almost always realign well with a push after numbing with local anaesthetic. The finger is held strpped to the next finger called neighbor or buddy strapping. Once healed there may be a mild bens to the side in the finger but it is not usually obvious and will almost always grow out straight over 1-2 years.


2.2 Proximal Phalanx Base (into the joint)

There are 2 main types of break:
                                                                                                                                                     A) Ligament Pull Off

An undisplaced break i.e. without a gap or small pull off fracture (representing a pull off of the ligament) can generally be treated with strapping to the next finger and careful movement for up to six weeks. If surgery is required such as for larger pieces of bone the finger is opened up from the palm and the break fixed with 1 or 2 small screws.

B) Breaks iin the middle of the base of the bone 

Most braks do not separate far so an operation is not needed. Rather the finger is supported in a plaster for 3-4 weeks and moved carefully from there.For simple breaks with 2 main pieces, if surgery is needed it can usually be done without opening the skin but passing 2 or 3 wires across the break using X-rays for guidance. The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries. Inevitably there will be long-term X-ray changes of arthritis in the injured joint but most people do not develop problems from this.

If there is are multiple bone fragments (comminution) then holding the fragments is much harder. Instead we use a system with a wire inserted into bone a little further up the finger and pulling it out (traction) but allowing some movement. Some surgeons favour opening the finger and inserting a plate and screws. This is however more complex and runs more risks.

2.3. Proximal Phalanx Shaft (mid-part of the bone)

(A) Transverse (straight across the bone)
If there is no tip or gap between the two halves of the break then initial protection for 1-3 weeks and movement from there gives very good results although many patients end up with a little stiffness in the finger. If there is a marked tip between the two halves of the break we first try to correct the tip with a push under local anaesthetic. This is often very successful. The finger is supported in a plaster cast for 3-4 weeks and moved carefully from there. Again a good outcome is expected, but with some finger stiffness.

If the break remains tipped or corrects and then tips back we usually wire the break along the line of the finger. The wire typically remains in place for 4-5 weeks. During this time the break and wire will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.                                                                                                  
(B) Crush injury
Typically these are stable fractures and often will do well with support in a plaster for the first two weeks and then careful movement. Inevitably with the severe damage to the soft tissues like skin, nerves, arteries tendons, and ligaments, there will be some stiffness, cold aching, swelling and possibly some loss of feeling.
With even more severe crush injuries the soft tissues may burst open. These will be less stable injuries and may need some support such as with a wire frame called an external fixator.

(C) Short oblique (short diagonal) breaks
Short oblique fractures are typically unstable even after being straightened out reduction. If there is only mild displacement or shortening such as 2-3 mm the finger can usually be supported in a plaster and watched carefully for 2-3 weeks. Careful movement can begin from 4-5 weeks after injury..
If the break is unstable following straightening we usually hold it with 1-3 wires inserted through the skin and avoiding opening the finger. The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.
An alternative is to open the finger and fix the fracture with screws or a plate and screws but this is rarely necessary in our experience.

(D) Long oblique (long diagonal) break
These will often shorten by 1 or 2 mm, but hold a reasonable position with only mild tip. This usually needs no further treatment other than support in plaster for 3-4 weeks and then careful movement.If the break has moved too much or will not hodl a good position after straightening then we recommend a push under local anaesthetic and holding the position with 3-4 wires passed through the skin and across the break. This is guided by X-rays in the operating theatre. The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries. Inevitably there will be long-term X-ray changes of arthritis in the injured joint but most people do not develop problems from this.
Most patients do well but there is often a little long-term stiffness in the middle joint of the finger.


(E) Spiral break
This is a common injury do to a twisting wrench of the finger. It often follows a fall whilst hoding a dog lead or horse reains, or carrying a bag such as a handbag or shopping. The concern is that the break will heal with a twist making function of the hand more difficult. The significance of the break is easy to miss soon after injury as twist of the finger can be difficult to assess early on.
It is very difficult to hold the finger with the twist straightened out without fixing it with wires or screws. We recommend pushing the break under local anaesthetic (or general anaethetic) and holding the correct position with 3-4 wires passed through the skin guided by X-rays in the operating theatre.
The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.
The alternative is open reduction held with 2-3 screws of a diameter of around 1.2 mm. This is technically more demanding and favoured by some surgeons. In our experience this is not usually necessary and we feel the extra risks are not worthwhile.


2.4. Proximal Phalanx Neck (outside the joint)

These are usually breaks straight across the bone which tip back. It occurs most commonly in late childhood and adolescence in adolescents. If there is little or no shift between the two halves of the break then the finger is protected in a splint or plaster for around 3 weeks. Further X-rays will be needed to ensure the fragments do not move in the first 1-2 weeks. After 3 weeksor so the patient can start protected movement.
If the two halves are displaced they will need to be pushed back into place. This may be stable enough to hold the break just with a plaster or splint. If not (this is often a judgment for the surgeon) then the break will need to be held with one or more wires. Under local or general anaesthetic the wires are put in through the skin without opening up the break.
The wires typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. Most patients do very well following these injuries.

 

2.5. Proximal Phalanx Head (into the joint) break

If there is little or no shift between the two halves of the break then the finger is protected in a splint or plaster for around 3-4 weeks. Further X-rays will be needed to ensure the fragments do not move in the first 1-2 weeks. After 3 weeksor so the patient can start protected movement.
If the two halves are displaced they will need to be pushed back into place. This is rarely stable enough to hold with a plaster or splint. In most cases the break will need to be held. Under local or general anaesthetic 1-4 wires are passed through the skin or the break is opened and the fracture fixed with 1-2 screws wires. Under local or general anaesthetic the wires are put in through the skin without opening up the break.
If wires are used they typically remain in place for 4-5 weeks. During this time the break and wires will need support in a plaster cast either a full cast or a partial cast. Any fingers or parts of fingers not held by the plaster should be moved to reduce stiffness. If screws are used then minimal if any extra support is needed and the patient is encouraged to start gentle movement of the finger straightaway. Most patients do very well following these injuries.

 

 

 

 

 

 
 

The Hand to Elbow Clinic
29a James Street West
Bath BA1 2BT

Tel 01225 316895
Fax 01225 484949
info@handtoelbow.com
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