Phalangeal Fractures

What is a phalangeal fracture?

A phalangeal fracture is a break in one of the small bones of the finger or thumb. Each finger has 3 phalanges, the thumb has two. You can see how the phalanges create the fingers and thumb in the photographs below. The first is a standard x-ray. The second shows the phalanges outlined on a photograph of a thumb.

Who is at risk for a phalangeal fracture?

Everybody is at risk for a phalangeal fracture. Hand injuries, specifically phalangeal injuries are extremely common in young children due to their frequent falls and high activity levels. Teenagers and adults participate in jobs, sports, and recreational activities which increase the likelihood of a phalangeal fracture. Elderly adults at risk for falls and who also have weakened bones are also at risk for phalangeal fractures.

The force associated with a phalangeal injury often increases the likelihood of a phalangeal fracture. For example, fingers which were slammed into a door or crushed by a heavy object are more likely to have a phalangeal fracture compared to a finger which was stubbed against an object. However, an important point to remember is that stubbed fingers can be fractured and can also sustain other injuries requiring treatment (tendon ruptures and joint dislocations).

What are the symptoms of a phalangeal fracture?

Any finger which maintains swelling, pain, numbness, bruising (in the skin or under the fingernail), deformity, loss of motion or function should be evaluated by a physician. Also, any finger which becomes cool and/or looses its normal color at any point in time after an injury needs to be seen by a physician immediately – this is a medical emergency.

Any finger which has the above symptoms and is thought to possibly be fractured should be seen urgently in the emergency room by a physician. The physician in the emergency room will determine the seriousness of the injury. The physician in the emergency room will also determine the optimum treatment which may involve care from an orthopaedic hand specialist.

What is the diagnosis of a phalangeal fracture?

The diagnosis of a phalangeal fracture is made primarily by physical examination along with an x-ray of the hand. The x-ray will help determine if the fracture involves the joint surfaces or if there is a small “hairline fracture”. In cases of finger deformity the x-ray will help differentiate between a joint dislocation, a fracture or both. Both a joint dislocation and a fracture can cause finger deformities and both need to be seen and treated by a physician. Any deep cut that extends to the fracture site is a medical emergency and needs to be treated in a hospital. Only a physician should determine if a deep cut communicates with the fracture.

What is the treatment for a phalangeal fracture ?

Possible fractures need to be evaluated by a physician as soon as possible. Delay of fracture evaluation may limit the treatment options available and could result in lifelong disabilities and deformities of the finger. The majority of phalangeal fractures can be treated by a physician without an operation. Fractures that are anatomically in place and fractures that stay in proper anatomical placement after being straightened by a physician (AKA stable fractures) do not require an operation. Fractures that do not have associated tendon, ligament, vessel, or a skin injury which extends down to the fracture can also be treated without an operation. Fractures that are managed without an operation are typically placed in a cast or splint for 3-4 weeks followed by range of motion exercises and “buddy taping” for another 2 weeks. After 5-6 weeks most fractures can resume all finger activities as tolerated by the patient.

A small number of fractures are not stable and require operative fixation to hold them in place. The fixation is achieved by the use of pins, screws, and plates. The pins, screws, and plates can be used individually or in combination with each other. Fractures managed with an operation may have a slightly longer healing time. Therefore, operative fractures are generally managed post-operatively with a cast or splint for 3-5 weeks followed by range of motion exercises and “buddy taping” for another 2-3 weeks. Most operative fractures can resume all finger activities as tolerated by the patient in 6-8 weeks.

First aid care for suspected phalangeal fractures includes washing out any cuts over the suspected fracture site with soap and water. A finger which is deformed should not be straightened by anyone who does not have advanced training in fracture management. Apply sterile (or clean if sterile dressings are not available) dressing to any cuts. Use dressings to help pad any deformities and then immobilize the injured finger by “buddy taping” the finger to its neighboring finger. If “buddy taping” is not an option any straight rigid object (pen or stick) can be used on the sides or back of the finger to create a splint which can be held on by tape. Seek emergency room care immediately.

What is the prognosis for phalangeal fractures?

The prognosis for all but the most severe types (those which the bone is severely smashed and involves the joint, tendon, or blood vessels) of phalangeal fractures examined and treated under the care of a physician is excellent. Almost all patients will regain full functional and pain free use of their finger with minimal to no residual problems. Complications occur mostly in untreated and operative fractures and include infection, non-union, malunion, hardware failure, neurovascular injury and joint stiffness. These complications although rare are a reality for any operation on the phalanges. Complications of an untreated fracture are significantly more common.

Tom Myers, MS4