Outcome of closed proximal phalangeal fractures of the hand

Abstract

Background: The proximal phalanx (PP) of the fingers is fractured more frequently than the middle or even distal phalanges. The problems of malunion, stiffness and sometimes loss of skin or other soft tissues associated with PP fracture increases the disability. The optimum treatment depends on fracture location, fracture geometry and fracture stability. The objective of the study was to analyse the treatment outcome in a series of closed proximal phalangeal fractures of the hand.

Materials and methods: Eighty-four proximal phalangeal fractures in 68 patients were enrolled from 2007 to 2009. The treatment modalities were broadly categorised into two groups, Group A consisted of conservative treatment, and Group B consisted of surgical treatment. Group A included 47 digits treated with closed reduction (CR) with immobilization (n=43), extension block cast and dynamic traction (n=4), while 37 digits were treated in Group B, which included closed or open reduction (OR) and internal fixation (IF) with K-wires (n=31), OR and IF with stainless-steel wiring (n=2), and mini external-fixator (n=4). Belsky's criteria and Gingrass' criteria were used for assessment of finger injuries and to assess the efficacy of conservative and surgical modalities for closed proximal phalangeal fractures of the hand.

Results: Average period of follow-up was 1 year (range 10-14 months). The excellent to good results seen in Groups A and B were 89% and 92%, respectively. Six complications were seen in Group A, which included four cases with malunion and two cases with digital stiffness. Three complications were seen in Group B, which included one each of malunion, digital stiffness and extensor lag. Overall, maximum poor results (n=4) were seen with CR and buddy strapping.

Conclusion: Conservative treatment is an inexpensive method, particularly suitable for stable fractures, and in patients who are poor candidates for surgery, Surgical modalities have distinct advantage of stable fixation, but with added risk of digital stiffness. Percutaneous pinning is a reliable, most commonly used surgical modality and technically easier. Both conservative and surgical modalities have good efficacy when used judiciously.

Keywords: Proximal phalanx fracture; closed reduction; hand; open reduction.

Figure 1

Flowchart for management of proximal phalangeal fractures

Figure 2

Closed reduction and buddy strapping and splint technique. (a) Radiograph of middle finger (anteroposterior view) showing fracture of PP of middle finger. (b and c) Buddy strapping after closed reduction with ice cream stick. (d) Post-strapping Cock-up slab. (e and f) Post-reduction radiograph (lateral and anteroposterior view) showing good position of fracture. (g and h) Clinical photograph of patient showing satisfactory range of movement at 6 weeks of follow-up

Figure 3

Closed reduction and internal fixation technique. (a and b) Radiograph of hand (oblique and anteroposterior view) showing fracture of PP of ring finger. (c and d) Post-reduction radiograph of hand (oblique and anteroposterior view) with 2 K-wires in situ. (e) Post-reduction clinical picture at 2 weeks of followup. (f and g) Patient achieved full range of movement at 6 months of followup

Figure 4

Open reduction and internal fixation technique. (a and b) Radiograph of hand (oblique and anteroposterior view) showing fracture of PP of little finger. (c to h) Peroperative photograph of surgical steps for fracture reduction. (i) Post-reduction radiograph of hand (oblique view) showing good position of fracture. (j and k) Clinical photograph of patient showing satisfactory range of movement at 6 weeks of follow-up

Figure 5

Mini external-fixation technique. (a) Intraoperative ‘C’ arm-assisted radiograph showing good fracture reduction of PP of little finger with external-fixator. (b-d) Postoperative clinical photographs. (e and f) Clinical photograph at 1 year followup showing full range of movement showing fixator in situ

Figure 6

Malunion following closed reduction and buddy strapping. (a and b) Radiograph showing fracture of PP of little finger. (c and d) Radiograph (anteroposterior and oblique view) showing malunited fracture at 6 months of follow-up. (e and f) Clinical photograph showing satisfactory range of movement with malunion at 6 months of follow-up

Figure 7

Post-treatment complications. (a) Clinical photograph with rotational deformity of middle finger. (b) Clinical photograph with extension lag of little finger. (c and d) Clinical photograph with malunion of little and middle fingers, respectively