Phalangeal Fractures
Proximal and middle phalanx fractures of the digits
Fracture Types
Critical Must-Knows
- Rotational malunion is the most functionally limiting deformity
- Check for scissoring - all fingers should point to scaphoid tubercle when flexed
- PP apex volar angulation from intrinsic pull on proximal fragment
- MP angulation varies - proximal apex volar (central slip), distal apex dorsal (FDS)
Clinical Pearls
- "Stable fractures: buddy tape + early motion
- "Unstable: K-wires, screws, or plate fixation
- "Unicondylar fractures often need ORIF to prevent angular deformity
- "Stiffness is the enemy - mobilize early when fixation stable
Rotation is King!
Rotational Assessment
All fingertips should point to SCAPHOID TUBERCLE when flexed. Look for SCISSORING of digits. Even 5 degrees rotation = 1.5cm overlap at fingertip. Rotational malunion is FUNCTIONALLY DEVASTATING.
Angulation Assessment
Apex volar angulation at PP (intrinsics pull proximal fragment). Variable angulation at MP (FDS vs central slip). Less angulation tolerated in index/long (more visible). More tolerated in ring/small (compensatory CMC motion).
At a Glance
| Scenario | Decision | Rationale |
|---|---|---|
| Stable, non-displaced fracture | Buddy tape + early motion | Low risk of displacement |
| Any rotational deformity | Closed reduction or ORIF | Cannot accept rotation |
| Transverse PP shaft fracture | K-wires or plate | High intrinsic deforming force |
| Short oblique/transverse | K-wires (cross-pattern) | Lag screws won't hold |
| Long spiral fracture | Lag screws | Ideal screw purchase |
| Comminuted fracture | Plate +/- bone graft | Need to span comminution |
| Unicondylar head/neck fracture | ORIF with screws | Prevent angular deformity |
| Bicondylar fracture | ORIF with mini-condylar plate | Restore articular surface |
| Open fracture | Irrigation, debridement, stabilization | Prevent infection |
| Pilon-type base fracture | Consider external fixation | Joint distraction helpful |
Mnemonics and Memory Aids
PHALANXPHALANX Fracture Assessment
| P | Position of fracture (base/shaft/neck/head) | A | Any rotation (scissoring test) |
| H | Handedness and occupation of patient | N | Nerve/vessel status (digital exam) |
| A | Angulation (apex direction and degree) | X | X-ray (PA, lateral, oblique views) |
| L | Length (shortening assessment) |
| P | Position of fracture (base/shaft/neck/head) | L | Length (shortening assessment) | X | X-ray (PA, lateral, oblique views) |
| H | Handedness and occupation of patient | A | Any rotation (scissoring test) | ||
| A | Angulation (apex direction and degree) | N | Nerve/vessel status (digital exam) |
Hook:Assess the whole PHALANX before deciding treatment!
SCISSORSCISSOR Test for Rotation
| S | Scaphoid tubercle - all fingertips should point here | S | Subtle rotation causes significant overlap |
| C | Check cascade in semiflexion | O | Open reduction if cannot correct |
| I | Individual finger exam in flexion | R | Rotational malunion is devastating |
| S | Side-to-side comparison essential |
| S | Scaphoid tubercle - all fingertips should point here | S | Side-to-side comparison essential | R | Rotational malunion is devastating |
| C | Check cascade in semiflexion | S | Subtle rotation causes significant overlap | ||
| I | Individual finger exam in flexion | O | Open reduction if cannot correct |
Hook:The SCISSOR test catches what others miss!
APEXAPEX Direction by Location
| A | At PP: APEX VOLAR (intrinsics pull proximal fragment into flexion) |
| P | Proximal MP: apex volar (central slip pulls) |
| E | Exact middle MP: minimal deformity (balanced forces) |
| X | X-tra distal MP: apex dorsal (FDS pulls middle fragment) |
| A | At PP: APEX VOLAR (intrinsics pull proximal fragment into flexion) | E | Exact middle MP: minimal deformity (balanced forces) |
| P | Proximal MP: apex volar (central slip pulls) | X | X-tra distal MP: apex dorsal (FDS pulls middle fragment) |
Hook:Know your APEX direction for proper reduction!
Overview
Overview
Phalangeal fractures are among the most common upper extremity injuries, representing approximately 10% of all fractures. The proximal phalanx (PP) and middle phalanx (MP) present distinct management challenges due to the complex interplay of tendons, ligaments, and muscles surrounding each bone. Understanding the deforming forces acting on these fractures is essential for appropriate reduction and stable fixation.
The primary goal of treatment is to restore anatomic alignment, particularly rotation, while allowing early mobilization to prevent the stiffness that is the major cause of poor outcomes in these injuries. Even minor rotational malalignment can result in significant functional impairment, with scissoring of digits during grip and pinch activities. The hand surgeon's mantra "stable fracture, mobile joint" encapsulates the treatment philosophy.
Classification is based on bone involved (PP vs MP), location (base, shaft, neck, head), and fracture pattern (transverse, oblique, spiral, comminuted). Each combination has specific biomechanical implications that guide treatment selection.
Anatomy and Biomechanics
Anatomy and Biomechanics
Proximal Phalanx Anatomy
Structural Features:
- Broadest at base, tapers distally
- Biconcave base articulates with MC head
- Bicondylar head articulates with MP base
- Rectangular cross-section (makes plating easier)
Tendon Relationships:
- Extensor mechanism dorsal (conjoined lateral bands)
- FDP tendon volar (in sheath)
- Interossei insert on base (volar to axis)
- Lumbricals cross volar to MCP joint
Deforming Forces - PP:
| Fragment | Deforming Force | Result |
|---|---|---|
| Proximal | Interossei | Flexion |
| Distal | Central slip + lateral bands | Extension |
| Result | Apex volar angulation |
Middle Phalanx Anatomy
Structural Features:
- Shortest phalanx
- Base biconcave, head bicondylar
- More tubular than PP
Tendon Relationships:
- Central slip inserts on dorsal base
- FDS splits and inserts on volar-lateral shaft
- FDP passes between FDS slips
- Lateral bands converge to form terminal tendon
Deforming Forces - MP:
| Fracture Level | Proximal Pull | Distal Pull | Apex Direction |
|---|---|---|---|
| Proximal to FDS | Central slip (extension) | FDS (flexion) | Apex volar |
| Distal to FDS | FDS (flexion) | Terminal tendon (extension) | Apex dorsal |
Vascular Supply
Digital Arteries:
- Proper digital arteries run along volar-lateral aspect
- Nutrient arteries enter volar cortex
- Periosteal stripping affects blood supply
Key Anatomical Points for Surgery
Safe Zones for K-wire Entry:
- Dorsal approach between extensor and lateral bands
- Avoid vincular system volarly
- Protect digital nerves at lateral aspect
Plate Placement:
- Lateral approach (between NV bundle and extensor)
- Dorsal approach (beneath extensor)
- Avoid volar plating (tendon adhesions)
Classification
Classification
Proximal Phalanx
| Location | Characteristics | Treatment Considerations |
|---|---|---|
| Base | Often intra-articular | May need ORIF for articular |
| Shaft | Strong deforming forces | K-wire or plate |
| Neck | Condylar fractures | Often need ORIF |
| Head | Unicondylar/bicondylar | ORIF for congruency |
Middle Phalanx
| Location | Characteristics | Treatment Considerations |
|---|---|---|
| Base | Often pilon-type | May need external fixation |
| Shaft | FDS insertion affects apex | Variable angulation |
| Neck | Rare | Reduction important |
| Head | Often associated with DIP injury | Rare |
AO/OTA Classification (Overview)
- A: Extra-articular
- B: Partial articular
- C: Complete articular
Clinical Presentation
Clinical Presentation
History
Mechanism:
- Direct blow (crush injury)
- Axial load (ball-handling sports)
- Twisting injury (spiral fractures)
- Fall on outstretched hand
- Industrial accidents
Key History Points:
- Hand dominance
- Occupation
- Sports/activities
- Previous hand injuries
- Time since injury
Physical Examination
Inspection:
- Swelling (localized vs diffuse)
- Deformity (angulation, shortening)
- Rotational malalignment
- Skin integrity (open fracture?)
- Nail bed alignment
Rotational Assessment - Critical:
- Semiflexion cascade: All fingertips should converge toward scaphoid tubercle
- Full flexion: Check for scissoring/overlap
- Finger extension: Assess nail plate alignment
- Compare to contralateral hand
Palpation:
- Point tenderness at fracture site
- Assess for crepitus (gentle)
- Evaluate stability
Neurovascular Examination:
- Digital sensation (radial and ulnar aspects)
- Capillary refill
- Allen test for digital arteries
Tendon Assessment:
- FDP function (DIP flexion)
- FDS function (isolated PIP flexion)
- Extensor function
- Note if pain limits assessment
Associated Injuries
- Tendon avulsions (mallet, jersey finger)
- Ligament injuries (collateral, volar plate)
- Nerve injuries (digital nerve laceration)
- Vascular injuries (in open fractures)
- Nail bed injuries
Differential Diagnosis
The painful, swollen, deformed finger has several mimics. The key discriminators are the presence of a cortical break on radiographs, the location of maximal tenderness, and whether the deformity is correctable.
Differential Diagnosis of the Injured Finger
| Condition | Typical History | Key Examination | Radiograph / Discriminator |
|---|---|---|---|
| Phalangeal fracture | Axial load, twist or crush | Point tenderness over shaft, possible scissoring | Cortical break; assess rotation and angulation |
| PIP / DIP dislocation | Hyperextension or axial load | Visible joint deformity, springy block to motion | Loss of joint congruity without a shaft fracture |
| Volar plate avulsion / PIP fracture-dislocation | Forced hyperextension (ball sport) | Volar PIP tenderness, dorsal instability | Small volar lip fragment at middle phalanx base |
| Mallet / jersey finger | Forced flexion (mallet) or hyperextension on grip (jersey) | Loss of active DIP extension or FDP flexion | Bony avulsion at distal phalanx base or none |
| Collateral ligament sprain | Lateral stress to finger | Tenderness over collateral, pain on lateral stress | Normal or small avulsion fleck; no shaft break |
| Enchondroma with pathological fracture | Low-energy injury, may be trivial | Often little soft-tissue reaction | Lytic expansile lesion, typically proximal phalanx |
Investigations
Investigations
Radiographic Assessment
Standard Views:
- PA (posteroanterior): Fracture pattern, shortening
- True lateral: Angulation, displacement
- Oblique: Rotational assessment, condylar fractures
Key Radiographic Assessment:
- Fracture location (base/shaft/neck/head)
- Fracture pattern (transverse/oblique/spiral)
- Angulation (degree and apex direction)
- Shortening
- Articular involvement
- Bone quality
CT Imaging
Indications:
- Articular fractures (condylar, pilon)
- Complex comminuted patterns
- Surgical planning
- Unclear fracture pattern on XR
CT Advantages:
- 3D reconstruction
- Fragment number and size
- Articular surface assessment
- Guide surgical approach
MRI (Limited Role)
- Suspected ligament injury
- Occult fractures
- Tendon pathology
- Not routine for fractures
Ultrasound
- Dynamic tendon assessment
- Soft tissue masses
- Guided injections
Management Algorithm
Management Algorithm
Non-Operative Treatment
Indications:
- Stable, non-displaced fractures
- Acceptable alignment maintained
- No rotational deformity
- Patient compliance expected
Techniques:
1. Buddy Taping:
- Tape affected finger to adjacent finger
- Provides stability through adjacent digit
- Allows early motion
- Ideal for stable fractures
2. Extension Block Splinting:
- For base fractures with dorsal angulation
- MCP in 70-90 degrees flexion
- Prevents dorsal displacement
3. Alumifoam Splint:
- Custom molded
- Immobilizes fracture
- Allows motion of unaffected joints
Protocol:
- Immobilization: 3-4 weeks
- Begin ROM exercises early when stable
- Buddy tape for protection 4-6 weeks total
- Hand therapy referral for optimal outcomes
Key Success Factor: Early mobilization when fracture stable prevents stiffness complications.
Surgical Technique
Surgical Technique
Cross K-Wire Pattern (Most Stable)
- Setup: Fluoroscopy, mini C-arm, 0.045" or 0.062" K-wires
- Reduction: Achieve closed reduction, hold with reduction forceps
- First wire: Insert dorsal-lateral, aim distal-medial, cross fracture site
- Second wire: Insert dorsal-medial, aim distal-lateral, cross first wire
- Check: PA and lateral fluoroscopy for reduction and wire position
- Finish: Cut and bend wires outside skin, apply dressing
Intramedullary Bouquet Technique
- Used for transverse fractures
- Multiple 0.028" K-wires inserted retrograde from fracture site
- Drive across fracture into proximal fragment
- Provides rotational and angular stability
- Wires buried beneath skin
Advantage: Wires buried beneath skin, reducing pin site infection risk compared to percutaneous technique.
Complications
Complications
Early Complications
Malreduction:
- Rotational most significant
- May require revision fixation
- Prevention better than treatment
Infection:
- Higher risk with open fractures
- Pin site infection with K-wires
- Deep infection rare with proper technique
Neurovascular Injury:
- Digital nerve during approach
- Vascular compromise (rare)
Fixation Failure:
- Screw loosening
- K-wire migration
- Plate failure in comminuted fractures
Late Complications
Stiffness:
- MOST COMMON complication
- Affects PIP joint primarily
- Results from:
- Prolonged immobilization
- Tendon adhesions
- Capsular contracture
- Prevention: early motion
Malunion:
- Rotational most functionally significant
- Angulation may be tolerated
- May require corrective osteotomy
Nonunion:
- Uncommon in phalanges
- Risk factors: comminution, infection, motion at fracture
- Treatment: bone graft + rigid fixation
Post-Traumatic Arthritis:
- After articular fractures
- Risk proportional to articular incongruity
- May need arthrodesis
Tendon Adhesions:
- Common after dorsal surgery
- Extensor lag or flexion loss
- May need tenolysis
Cold Intolerance:
- Common in first year
- Usually improves
Comparison of Complication Risk
| Complication | K-wire | Screw | Plate |
|---|---|---|---|
| Pin track infection | High | N/A | N/A |
| Stiffness | Low-Mod | Low | Moderate |
| Tendon adhesion | Low | Low | Higher |
| Hardware removal | Common | Rare | Sometimes |
Postoperative Care
Postoperative Care
Week 0-1: Protection Phase
Goals:
- Wound healing
- Control edema
- Protect fixation
Protocol:
- Splint protection (volar slab with MCP in flexion)
- Hand elevation above heart level
- Ice therapy 20 minutes every 2 hours
- Digital ROM exercises if fixation is rigid (plate/screws)
- K-wire cases: splint immobilization
- Monitor for infection (increased pain, erythema, drainage)
Wound Care:
- Dressing change at 2-3 days
- Suture removal at 10-14 days
- Pin site care (K-wires): daily cleaning with chlorhexidine
Week 1-3: Early Motion Phase
Goals:
- Prevent stiffness
- Maintain reduction
- Progress ROM
Protocol:
- Remove sutures at 10-14 days
- Hand therapy referral
- Active ROM exercises:
- MCP, PIP, DIP flexion/extension
- Tendon gliding exercises
- Place and hold exercises
- Avoid passive stretching initially
- Splint between exercises
- Edema control: compression glove, elevation, retrograde massage
K-Wire Management:
- Continue splint protection
- Active ROM of adjacent joints
- Pin site monitoring
Week 3-6: Progressive Motion Phase
Goals:
- Increase ROM
- Begin light functional use
- Remove K-wires if used
Protocol:
- Remove K-wires at 3-4 weeks (when fracture sticky)
- Increase frequency of ROM exercises
- Begin passive ROM (gentle)
- Dynamic splinting if stiffness developing:
- Extension turnbuckle for PIP flexion contracture
- Flexion strap for extension lag
- Light functional activities
- Buddy taping for protection
Radiographic Follow-up:
- XR at K-wire removal to confirm alignment maintained
- Check for callus formation
Week 6-12: Strengthening Phase
Goals:
- Restore grip strength
- Return to function
- Maximize ROM
Protocol:
- Progressive strengthening exercises:
- Putty exercises (soft to firm progression)
- Gripper exercises
- Functional activities
- Sport-specific training
- Work conditioning program
- Continue ROM exercises to plateau
Return to Activities:
- Desk work: 1-2 weeks (with protection)
- Light manual work: 6-8 weeks
- Heavy manual work: 10-12 weeks
- Contact sports: 10-12 weeks (with protection initially)
Hardware Removal
Indications for Removal:
- Symptomatic hardware (prominence, pain)
- Patient request
- Plate/screw removal: generally only if symptomatic
Timing:
- K-wires: 3-4 weeks routine
- Screws/plates: after fracture consolidation (12+ weeks) if needed
Red Flags Requiring Review
- Increasing pain after initial improvement
- Loss of reduction on radiographs
- Signs of infection (erythema, purulent drainage, fever)
- Worsening stiffness despite therapy
- Neurovascular compromise
- Pin migration or loosening
Outcomes and Prognosis
Outcomes and Prognosis
Prognostic Factors
Good Prognosis:
- Simple fracture pattern
- Anatomic reduction (especially rotation)
- Early motion achieved
- Young patient
- Single digit involved
Poor Prognosis:
- Comminuted fracture
- Residual rotation
- Prolonged immobilization
- Index/long finger (less CMC compensation)
- Multiple digit involvement
- Associated soft tissue injury
Expected Outcomes by Fixation
Conservative Treatment:
- 90% good/excellent for stable fractures
- ROM typically 80-90% of contralateral
- Minimal grip strength deficit
K-Wire Fixation:
- 80-85% good/excellent
- Stiffness main complication
- Slight grip strength reduction
Screw/Plate Fixation:
- 85-90% good/excellent
- Best ROM preservation
- Hardware issues may require removal
Return to Activity
| Activity | Timeframe |
|---|---|
| Desk work | 1-2 weeks (with splint) |
| Light manual work | 6-8 weeks |
| Heavy manual work | 10-12 weeks |
| Contact sports | 10-12 weeks |
| Full grip strength | 3-6 months |
Evidence and Guidelines
Evidence Base
Epidemiology of Hand Fractures
- Prospective single-unit data on 1382 patients (1569 metacarpal and phalangeal fractures) gave a hand fracture incidence of 3.7 per 1000 per year in men and 1.3 per 1000 per year in women, with gender-specific mechanisms
Comprehensive Review - Principles of Phalangeal Fracture Care
- Across phalangeal fracture patterns the guiding principles are anatomic reduction (particularly rotation, the least-tolerated deformity), stable fixation and early postoperative mobilisation; reported complication rates after internal fixation remain variable and represent an unsolved problem
K-Wire vs Plate Fixation (Randomised Controlled Trial)
- RCT of 40 unstable proximal/middle phalangeal diaphyseal fractures: lateral titanium plate-and-screw fixation gave significantly higher total active motion and fewer complications (2 of 20) than percutaneous K-wires (5 of 20); grip strength and patient-reported scores were similar
Early Mobilisation and Treatment Principles
- Review of extra-articular metacarpal and phalangeal fractures emphasises that treatment must restore anatomy while mobilising the digital chain as early as possible in every patient, with regular follow-up to detect secondary displacement
Distal Unicondylar Fractures of the Proximal Phalanx
- Series of 38 distal unicondylar proximal phalanx fractures: 5 of 7 nondisplaced fractures treated by splinting and 4 of 10 displaced fractures fixed with a single K-wire displaced; multiple K-wire or miniscrew fixation gave the best final joint motion
Metacarpal and Phalangeal Fractures in Athletes
- Metacarpal and phalangeal fractures account for about 10% of all fractures and roughly a quarter occur during sport; evolving fixation allows early range of motion and earlier return to play, with stiffness the principal functional threat
Viva Questions
Viva Scenarios
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
"A 35-year-old carpenter presents with a spiral fracture of the proximal phalanx of his ring finger sustained while using a power tool. There is 20 degrees of apex volar angulation and you suspect rotational malalignment. Describe your assessment and management."
Key Discussion Points:
- Rotational malalignment is NEVER acceptable - must correct surgically
- Spiral fractures: ideal for lag screw fixation (2-3 screws minimum)
- Rule: spiral length should be at least 2x bone diameter for screws
- PP apex volar angulation from intrinsic pull on proximal fragment
- Carpenter - needs full function for occupation
- Lateral approach: between NV bundle and lateral band
- Post-op: early motion to prevent stiffness
- Hand therapy critical for optimal outcome
"Explain the deforming forces acting on proximal phalanx fractures and why the apex of angulation is volar."
Key Discussion Points:
- Interosseous muscles insert on volar aspect of PP base
- Lumbricals also pass volar to MCP axis
- These FLEX the proximal fragment
- Central slip and lateral bands attach to distal fragment
- Extensor mechanism EXTENDS the distal fragment
- Result: proximal fragment flexes, distal extends
- Creates APEX VOLAR angulation
- Reduction: MCP flexion relaxes intrinsics, easier reduction
- Immobilization: intrinsic-plus position (MCP 70°, IP extended)
"A patient presents 3 weeks after injury with a stiff PIP joint following a middle phalanx shaft fracture that was treated in a splint. The fracture is uniting. What are the causes of stiffness and how would you manage this?"
Key Discussion Points:
- Stiffness is most common complication of phalangeal fractures
- PIP joint particularly prone to stiffness
- Causes: immobilization, edema, capsular contracture, tendon adhesions
- Prevention better than treatment: early motion when stable
- Immobilization beyond 3 weeks increases stiffness risk
- Treatment: hand therapy is cornerstone (ROM, splinting, scar management)
- Dynamic splinting: constant gentle force more effective than aggressive therapy
- Surgical options: capsulotomy, tenolysis (after 6 months if plateau)
- This case: 3 weeks immobilization is borderline - start therapy now
MCQ Practice Points
MCQ Practice Points
High-Yield Facts
Rotational Malalignment - The Deal Breaker
Q: Why is rotational malalignment the most critical assessment? A: 5° rotation = 1.5cm fingertip overlap - Even minor rotation causes functional scissoring. Unlike angulation, rotation does not remodel and causes permanent impairment. All fingertips must point to the scaphoid tubercle.
Deforming Forces - Know Your Apex
Q: What is the typical deformity of a proximal phalanx fracture? A: Apex Volar - The interossei flex the proximal fragment, while the central slip extends the distal fragment. Reduction requires flexing the MCP joint to relax the intrinsics.
Fixation Rules - Spiral vs Transverse
Q: When is lag screw fixation indicated? A: Long spiral fractures (greater than 2x bone diameter) - Requires sufficient length for 2-3 screws. Short oblique or transverse fractures require K-wires or plating as screws won't hold.
Stiffness - The Enemy
Q: what is the most common complication of phalangeal fractures? A: PIP Joint Stiffness - Risk increases significantly with immobilization greater than 3 weeks. The goal of fixation is "stable fracture, mobile joint" to allow immediate motion.
Surgical Approach Hazards
Q: Why is the volar approach avoided for phalangeal plating? A: Tendon Adhesions - The flexor tendons (FDS/FDP) are prone to adherence to the plate, causing stiffness. Lateral (preferred) or dorsal approaches are safer.
Unicondylar Fractures
Q: How must displaced unicondylar fractures be treated? A: ORIF - These are unstable intra-articular fractures. Without fixation, the condyle displaces proximally, causing angular deformity and arthritis.
Common Exam Traps
Trap 1: Accepting small rotational deformity
- WRONG: "5 degrees is minor"
- RIGHT: NO rotation acceptable (5° = 1.5cm overlap)
Trap 2: Using lag screws for short oblique fractures
- WRONG: Screws for all oblique fractures
- RIGHT: Need length at least 2x diameter for screw purchase
Trap 3: Volar approach for plating
- WRONG: Direct access to fracture
- RIGHT: NEVER volar (massive tendon adhesions)
Trap 4: Prolonged immobilization
- WRONG: "Immobilize 6 weeks for healing"
- RIGHT: Maximum 3 weeks if possible, early motion critical
Trap 5: Ignoring deforming forces
- WRONG: Just reduce the fracture
- RIGHT: Must understand apex direction (PP = volar, MP = variable)
Guidelines, Registries & Global Practice
Guidelines, Registries and Global Practice
Global Epidemiology
Phalangeal and metacarpal fractures are among the commonest skeletal injuries, accounting for approximately 10% of all fractures, with roughly a quarter occurring during sport. [Cotterell & Richard 2014; PMID 25455397] Prospective population data from a single trauma unit reported a hand fracture incidence of 3.7 per 1000 per year in men and 1.3 per 1000 per year in women, with a marked young-male predominance and gender-specific mechanisms (assault and sport in men; falls in older women). [Anakwe et al. 2010; PMID 20709710]
| Parameter | Figure | Source population |
|---|---|---|
| Hand fractures as proportion of all fractures | ~10% | Mixed (review) |
| Sport-related share | ~25% | Mixed (review) |
| Incidence (men) | 3.7 per 1000 per year | Edinburgh trauma unit |
| Incidence (women) | 1.3 per 1000 per year | Edinburgh trauma unit |
| Peak demographic | Young men; second peak in older women | Edinburgh trauma unit |
Major Guidance, Side by Side
There is no single high-level international guideline dedicated to phalangeal fractures; practice is driven by hand-surgery society teaching, the AO Foundation principles and consistent themes across narrative reviews and one randomised trial. The areas of genuine consensus and the few areas of variation are summarised below.
| Body / Source | Position | Evidence level |
|---|---|---|
| AO Foundation (hand) | Stable fixation tailored to pattern (lag screws for long oblique/spiral, plates for transverse/comminuted), preserve soft tissue, enable early motion | Expert consensus / biomechanical |
| BSSH / IFSSH teaching (UK & international hand societies) | Most extra-articular fractures with acceptable alignment and no malrotation are treated non-operatively with buddy strapping and early movement | Expert consensus |
| ASSH / North American hand surgery | Same principles; midlateral plating or screws where unstable; early protected motion | Expert consensus |
| Comprehensive reviews | Anatomic reduction (rotation least tolerated), stability adequate for early mobilisation; complication rates after fixation remain variable | Level V [PMID 37704026, 24486016] |
| Randomised trial evidence | Lateral plate-and-screw fixation gave higher total active motion and fewer complications than K-wires in unstable diaphyseal fractures | Level II [PMID 30803743] |
Registry Evidence
Unlike arthroplasty, phalangeal fractures are not tracked by national joint registries (NJR, AJRR, AOANJRR, SHAR), so high-volume implant-survival data do not exist for this topic. The best comparative evidence is therefore the single randomised controlled trial above plus prospective and retrospective hand-surgery series, rather than registry output. This is an important point to make explicitly in a viva: the evidence base is dominated by Level II–IV studies.
Global Practice Variation
- Resource setting: K-wires are inexpensive, universally available and remain the workhorse in limited-resource settings; plate-and-screw systems and image intensifiers concentrate the cost and are more variably available.
- Specialty delivery: hand trauma is delivered by orthopaedic, plastic or dedicated hand surgeons depending on region, which influences thresholds for operative fixation.
- Rehabilitation access: outcomes hinge on early hand therapy; access to specialist hand therapists varies widely between and within countries and is a key determinant of the stiffness that dominates poor results.
- Consistent worldwide principle: regardless of system, malrotation is never accepted, and the goal is a stable fracture with an early-moving joint.
Exam Cheat Sheet
Exam Day Cheat Sheet
Phalangeal Fractures - Key Points
Clinical summary
Critical Assessment
- •ROTATION - most important (check scissoring)
- •All fingertips point to scaphoid tubercle in flexion
- •5 degrees rotation = 1.5cm fingertip overlap
- •No rotation is acceptable
Deforming Forces
- •PP: apex VOLAR (intrinsics flex proximal fragment)
- •MP proximal to FDS: apex volar (central slip)
- •MP distal to FDS: apex dorsal (FDS pulls)
- •MCP flexion relaxes intrinsics for reduction
Fixation Selection
- •Stable: buddy tape + early motion
- •Transverse/short oblique: K-wires or plate
- •Long spiral: lag screws (2-3 minimum)
- •Comminuted: plate to bridge
Complications
- •Stiffness - MOST COMMON complication
- •Prevention: early motion when stable
- •Malunion - rotational most significant
- •Adhesions - avoid volar plating
Quick Reference: Key Numbers
| Parameter | Value |
|---|---|
| PP angulation acceptable | 10-15° |
| MP angulation acceptable | 15-20° |
| Rotation acceptable | NONE (0°) |
| 5° rotation overlap | 1.5cm at tip |
| Max immobilization | 3 weeks ideal |
| Lag screw minimum | 2 (prefer 3) |
| Spiral length for screw | at least 2x diameter |
| Return to full activity | 10-12 weeks |