August 29, 2021

Review of Hand Distal Phalanx Fractures

Introduction

Fractures of the distal phalanx can be divided into the base, shaft, and tuft and are typically managed non-operatively. Distal phalanx fractures are commonly seen during football season. The distal phalanx is made up of the base, shaft, and tuft (1). Both sides of the distal phalanx are flanked by the lateral interosseous ligament and there is also a collateral ligament surrounding the distal interphalangeal joint (1). There are also insertions of the flexor digitorum profundus and extensor tendon (1).  The FDP inserts on the volar and proximal aspect of the phalanx, while the extensor tendon is on the dorsal and proximal portion of the phalanx (6). Fractures of the distal phalanx are typically painful due to high amount of sensory nerves present along the distal phalanx (6). Most fractures of the distal phalanx are secondary to crush injuries (7).

Case Vignette

You are evaluating a 23 year old patient with a finger injury in your clinic. He states it got crushed while he was changing a tire on his car. Statistically, which fracture is he most likely to have on his distal phalanx?

A) Tuft
B) Shaft
C) Intra-articular
D) Base

distal phalanx xray

Image 1. Labeled xray of the distal phalanx (1)

Diagnosis

Physical exam of a hand injury starts with evaluation of the soft tissue for swelling and bruising (2). The digit should also be evaluated for shortening and rotation (2). Asking the patient to actively flex their fingers into a fist will assess for rotational deformity (3). Neurovascular assessment for arterial and nerve injury should also be assessed with light touch and checking the pulses (2). Range of motion of the digit is done to evaluate for ruptured tendon (2).

Diagnosis of an avulsion fracture can be made with radiographs. Three views of the digit are necessary including the AP, lateral, and oblique (2). Typically, the fracture segment can be evaluated with the lateral view. A bony avulsion can occur on the flexor surface and be associated with FDP avulsion (1). There is also dorsal avulsion of the proximal base of the phalanx, which could be due to extensor tendon rupture and is also known as a bony mallet finger (1). Fractures can also occur at the distal portion, known as the tuft, as well as the middle portion, known as the shaft (1).  

Image 2. Insertions of the FDP and extensor tendon (1)

Treatment

The most common fracture of the distal phalanx is the tuft fracture (2). Nondisplaced fractures of the tuft without nail bed injury can be managed conservatively with distal phalanx splinting (1). Damage to the nail bed requires nail bed repair (3). Subungual hematomas can also be drained with trephination with an 18g needle (4). These can be drained within the first 48 hours, otherwise the clot will be too difficult to drain (7). Hand rehabilitation will focus on active range of motion within the first week for a tuft fracture (6). The goal is to allow unrestricted passive range of motion by the fourth week (6).

Shaft fractures are also usually treated nonoperatively due to the surrounding soft tissue support (1). Surgical management should be considered if the fracture is unstable and with significant angulation (1). Surgical treatment typically includes use of K-wires or screw fixation (4). Most fractures will need to be splinted for two to three weeks while allowing for proximal interphalangeal joint motion (3).

Conclusion

Fractures of the distal phalanx are typically treated nonoperatively. The most common fracture seen is a tuft fracture. Splinting in extension for two to three weeks is the typical nonoperative treatment. Displaced and angulated fractures need referral to hand surgery.

 

By Gregory Rubin, DO

rubinsportsmed.com

Case Conclusion

Answer: The most common fracture of the distal phalanx is a tuft fracture. The tuft is the most distal portion of the phalanx. They are typically treated non-operatively with splinting in extension for two to three weeks.

Liao, Janice C. Y., and Soumen Das De. “Management of Tendon and Bony Injuries of the Distal Phalanx.” Hand Clinics, vol. 37, no. 1, Feb. 2021, pp. 27–42.

Hile, David, and Lisa Hile. “The Emergent Evaluation and Treatment of Hand Injuries.” Emergency Medicine Clinics of North America, vol. 33, no. 2, May 2015, pp. 397–408.

References

  1. Liao, Janice C. Y., and Soumen Das De. “Management of Tendon and Bony Injuries of the Distal Phalanx.” Hand Clinics, vol. 37, no. 1, Feb. 2021, pp. 27–42. PubMed, https://doi.org/10.1016/j.hcl.2020.09.005.
  2. Hile, David, and Lisa Hile. “The Emergent Evaluation and Treatment of Hand Injuries.” Emergency Medicine Clinics of North America, vol. 33, no. 2, May 2015, pp. 397–408. PubMed, https://doi.org/10.1016/j.emc.2014.12.009.
  3. Gaston, R. Glenn, and Christopher Chadderdon. “Phalangeal Fractures: Displaced/Nondisplaced.” Hand Clinics, vol. 28, no. 3, Aug. 2012, pp. 395–401, x. PubMed, https://doi.org/10.1016/j.hcl.2012.05.032.
  4. Evans, Peter, and Khurram Pervaiz. “Sports Specific Commentary: Phalangeal Fractures in Basketball.” Hand Clinics, vol. 28, no. 3, Aug. 2012, p. 405. PubMed, https://doi.org/10.1016/j.hcl.2012.05.034.
  5. Bourland, Bryan, et al. “Fingertip Injuries in Athletes, Musicians, and Other Special Cases.” Hand Clinics, vol. 37, no. 1, Feb. 2021, pp. 117–23. PubMed, https://doi.org/10.1016/j.hcl.2020.09.012.
  6. Cannon, Nancy M. “Rehabilitation Approaches for Distal and Middle Phalanx Fractures of the Hand.” Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists, vol. 16, no. 2, June 2003, pp. 105–16. PubMed, https://doi.org/10.1016/s0894-1130(03)80006-6.
  7. Petering, Ryan. Fracture Management for Primary Care and Emergency Medicine. Elsevier, 2020.

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