What is Phalanx Fractures of the Hand?
Phalanx fractures, or broken bones in the fingers, are among the most common human fractures, particularly in the upper limbs. They can lead to a host of complications, chiefly affecting the function of the hand and fingers. Despite this, they usually heal well through either non-invasive or surgical means.
Finger fractures can be categorized according to their location – at the base, shaft, or condyle of the finger – as well as the angle and displacement of the break. Therefore, a good understanding of the complex anatomy of the fingers is necessary for accurate diagnosis and treatment.
Each thumb consists of two segments known as the proximal and distal phalanx, whereas the other fingers – index, middle, ring, and little – have three segments: proximal, middle, and distal phalanges. The proximal and middle parts of each finger can be further divided into a base, shaft, and head from top to bottom. The heads of these segments have two rounded parts separated by a notch. Each segment has a slight inward curve except the straighter distal phalanx which ends with the nail. The structure of this last phalanx includes a base, shaft, and tuft.
Each finger segment articulates with others to form different joints. The base of the proximal phalanx connects with the metacarpal bone to form the metacarpophalangeal joint (knuckles). The bases of the middle and distal phalanges of the fingers form the proximal and distal joints respectively, by connecting with the heads of their neighbouring segments. In the thumb, this articulation occurs between the proximal and distal phalanges to form the thumb joint. Ligaments on each side of these joints become most rigid at a right angle.
The soft tissues surrounding the phalanges are intricate, with mechanisms for bending and stretching that assist in movement and stabilize broken bone fragments. The finger-bending flexor digitorum superficialis and flexor digitorum profundus tendons run over the inner surface of the hand and finger joints, bridging the different bone sections. The tendon network of vincula tethers the flexor tendons to the bone. On the back of the finger, the extensor tendons form a hoodlike expansion, attaching to the base of the middle and distal phalanges. Hand muscles connect to these extensor tendons on each side of the finger.
Lastly, a single nerve and artery run along both the thumb and pinky sides of the finger, nourishing the surrounding soft tissue and surface structures with small branches and tiny blood vessels.
What Causes Phalanx Fractures of the Hand?
Fractures in the bones of the hand, called phalanx fractures, often come from blunt force, sharp objects, or being crushed. Nevertheless, we also have to consider health-related causes such as tumors and infections. In general, the most frequent reasons for hand fractures are falls, crushing injuries, and sports-related incidents.
For young children under eight, the usual cause of hand fractures is their hand being shut in a door. Older children tend to get these fractures from falls and sports injuries. Other typical reasons for hand fractures in children include machinery accidents, car crashes, and injuries from heavy objects.
Risk Factors and Frequency for Phalanx Fractures of the Hand
Phalanx fractures, which are breaks in one of the bones in the fingers, happen to about 0.012% of people in the U.S. every year. These fractures are the second most common types of break in the upper body. They make up 23% of upper body fractures diagnosed in emergency rooms. People aged 45 to 85 experience these fractures the most, but they become the most common type for individuals over 85.
Interesting enough, the occurrence of these fractures seems to be lower in individuals with higher socioeconomic status. Hand and finger fractures also happen to boys more than girls and are more common in adult men than women. Both hands, right and left, are equally likely to be injured. Breaking the small, ring, and long fingers happens more than the thumb or index finger.
- Phalanx fractures happen in about 0.012% of the population yearly.
- They are the second most common break in the upper body.
- They make up 23% of upper body fractures diagnosed in emergency departments.
- Most commonly occur in individuals between 45 and 85, and most common for individuals over 85.
- Incidence decreases with higher socioeconomic status.
- Hand and finger fractures are more common in boys than girls and more common in adult men than women.
- Both hands, left and right, are equally likely to get fractured.
- The small, ring, and long fingers are the most commonly fractured.
Signs and Symptoms of Phalanx Fractures of the Hand
When someone has an injury, how they got hurt should match up with the type and seriousness of the injury. If it doesn’t, the person could have a fracture caused by a tumor or infection, or they might be a victim of physical abuse. Common causes of injuries include falls, crush injuries, and sports accidents. Symptoms can include pain, swelling, a change in shape, limited movement, or instability around the place they got hurt.
By observing the injury, you might notice a twisting or bending outward of the finger arising from the middle of finger bone or near any of the nearby joints. This twisting is best checked when the fingers are bent and straightened. All the fingers should be pointing towards the scaphoid tubercle (a small hump on one of the bones in your wrist). If the fingers look like they are overlapping or crossing each other, it might mean there is a twisting injury, but not always, as this can also be down to the person’s individual anatomy.
Touching the injury might find tenderness over the fracture site or damaged soft tissue areas. It’s important to examine the skin and soft tissues around the hand and fingers since the damage from these types of injuries can be quite extensive.
The range of movement of the injured finger and nearby joints are often limited due to the pain and early swelling. Numbing the area using a local anesthetic can help to relieve pain and make it easier to assess the finger’s alignment, range of motion, and strength. It should be noted that this must not be performed before a detailed neurovascular exam, which looks at the supply of nerves and blood vessels to the hand.
The nervous system status can be evaluated by checking sensation, two-point discrimination (ability to distinguish between two points on the skin), and motor function. Depending on the injury to the soft tissues, the results might range from fully normal to any level of deficit. The nerves on either side of the finger typically supply sensation to half of the digit, but there can be some overlapping sensation on top and bottom surfaces.
The finger’s blood supply can be examined by looking at skin color as well as how quickly the skin and nail bed regain their normal color after being pressed. It should be noted, a finger that has a cut to only one of its blood vessels will still regain color quickly, but it might be slower and the skin may appear slightly dusky.
Testing for Phalanx Fractures of the Hand
To diagnose a phalanx fracture, which is a break in one of the bones of the fingers, doctors often use X-rays of the hand from different angles. These images can provide detailed information about the areas suspected to have damage. If the X-ray results aren’t clear, doctors can compare them to the images of the unaffected hand, especially in younger patients whose bones are still growing.
X-rays reveal not only the fractures but also any misalignments or abnormal positioning of the bones. They can also show swelling in the soft tissues and any other changes related to aging, cancer, arthritis, or metabolic disorders that might be visible in the hand.
While X-rays are the standard tool, doctors are starting to use musculoskeletal ultrasound more frequently to diagnose phalanx fractures and accompanying soft-tissue injuries. Computed tomography, or CT scans, may be used to get a clearer picture of more complicated fractures, such as those involving shattered bones or fractures within a joint, or to better understand fractures caused by disease.
Magnetic Resonance Imaging (MRI) is rarely used but can be helpful in assessing associated soft tissue injuries and disease-related fractures.
Treatment Options for Phalanx Fractures of the Hand
The main goal when treating fractures of the hand’s phalanx bone is to properly heal the fracture while avoiding complications like stiffness, deformity, and tissue damage that can potentially impact the hand’s function. Both nonsurgical and surgical treatments come with pros and cons. For instance, nonsurgical treatments often prevent scar tissue formation, but require a period of immobilization. However, surgical treatments may defer this by allowing for earlier mobility but can lead to increased scar formation and tissue damage.
Nonsurgical treatment for hand fractures often includes a method known as closed reduction, where the bone is set back into place without incision, taping the injured finger to an adjacent finger for support, and restricting movement for a short period of time for healing. They may also need physical therapy. Surgery is not often necessary for extra-articular fractures at the tip of the finger due to the stability provided by the surrounding soft tissues, including the nail. But, if the nail bed or germinal matrix is lacerated, the nail needs to be removed and the laceration treated to prevent future nail deformities.
Surgery is usually recommended for other types of fractures in the hand, particularly in children. Certain fractures, known as Seymour fractures, occur in children when the growth plate in the finger is also injured and the wound is open. This fracture complicates healing and increases the risk of infection and growth plate damage. The treatment involves nail plate removal, cleaning the wound, wound repair, and antibiotics. In some cases, a small pin known as a Kirschner wire may be used for better alignment and stabilization. If the condition cannot be improved with these techniques, surgery should be considered to avoid further damage to the growth plate.
If an open wound is associated with the fracture, if the fracture is unstable and could lead to deformity or decreased hand function, or in cases of multiple displaced fractures in the hand, surgical treatment is typically recommended. The most common surgical methods for repairing these fractures include closed reduction with percutaneous pinning using Kirschner wires, or open reduction with internal fixation. The decision of which method to use will depend on the nature of the fracture and the potential for tissue damage.
When the fracture involves the joint, surgery is typically performed if there is a joint dislocation or if the arrangement of the fractured bones impairs mobility or increases the risk of developing osteoarthritis later on. However, opinions on the best treatment option vary among hand surgeons due to the variety of fractures and associated conditions that can occur. Methods like wire fixation with extension blocking, dynamic external fixation, and even partial joint replacement have been suggested as potential treatment options.
What else can Phalanx Fractures of the Hand be?
In adults, broken fingers, also known as phalanx fractures, are usually diagnosed correctly if backed by the right set of tests and exams. However, the story differs when it comes to children. A recent study revealed an 8% misdiagnosis rate in diagnosing broken fingers in children. This is probably due to lack of experience in recognizing subtle signs in a child’s growing bones where misjudgments can lead to under- or over-diagnosis.
Note that a broken finger isn’t always just a broken finger – there are other possible linked conditions which may be overlooked:
- Pathologic fracture – Some hands may have tumors or infections that weaken the bone, resulting in a break when faced with trauma. These conditions may be first noticed when a fracture occurs.
- Sprain in the collateral ligament – This is a sprain in the tough bands of tissue that connect the bones in the finger joint.
- Volar plate injury – This refers to an injury to the strong ligament found at the base of the finger that prevents it from bending back too far and hyperextending.
- Tendon rupture or cut – This could occur if the tendons which move the finger are damaged.
- Bone bruise – A serious injury that’s more significant than a typical bruise but less severe than a fracture.
- Dislocation/subluxation – This is when the finger bone moves out of place from the joint.
The doctor must consider these potential complications while diagnosing a broken finger.
What to expect with Phalanx Fractures of the Hand
While there are a relatively high number of complications from surgery for phalanx (finger or toe bone) fractures, the overall outlook is generally positive. Most of these fractures will heal, no matter what surgery method is used, but there are some instances of delayed healing, improper healing, and non-healing. Long-term complications, such as reduced movement range and deformity, are often observed.
Nevertheless, a majority of patients tend to recover well enough to return to work, with most people resuming their original jobs. Only a few need additional surgery to ensure that the fracture heals or to improve their ability to function.
Possible Complications When Diagnosed with Phalanx Fractures of the Hand
A significant number of people who have surgery for broken fingers (phalangeal fractures) experience complications. These issues can include stiffness, problems with the surgical implants (hardware failure), and infection. It’s also been shown that the older the patient is at the time of the injury, the less movement they might recover after surgery.
Some people have problems with their healing process. These can include a delay in the bones joining back together, bones not joining correctly or not joining at all, as well as constant pain. While many of these issues are considered minor, a few of them need another operation. This can involve adjusting the previous operation, taking out the surgical implants, freeing a tendon that has become restricted (tenolysis), and opening up a tight joint capsule (capsulotomy).
The common complications are:
- Stiffness
- Hardware failure
- Infection
- Delayed healing
- Bones not joining correctly
- Bones not joining at all
- Persistent pain
And the procedures that might be required for these issues include:
- Revision fixation
- Removal of hardware
- Tenolysis
- Capsulotomy
Recovery from Phalanx Fractures of the Hand
It’s important to start moving as soon as possible after phalanx fractures (fractures in the finger or toe bones) to help restore function. This usually starts once the fracture is healed enough to be stable. When this happens can vary and often begins within a few days of surgery. Techniques to keep the fractured area immobilised typically last for 3 to 6 weeks, but it’s not unusual for movement exercises to begin before immobilisation ends.
The method of rehabilitation can vary. It could be exercises done at home driven by the patient themselves, or formal sessions led by a hand therapist. The choice depends on how serious the injury is, how much motion was limited early on, and what the patient can do.
A successful rehabilitation program will focus on several key areas. These include good communication, controlling swelling (edema), starting movement early, and using strategies to reduce the sensitivity of scar tissue.
Preventing Phalanx Fractures of the Hand
To prevent injuries to the fingers and hands, including fractures, it’s crucial to limit exposure to potentially harmful situations and use protective gear. For example, doors can be fitted with safety mechanisms to prevent children from accidentally slamming their fingers in them. Protective gloves and rules designed to keep hands away from danger during sports can also add an extra layer of safeguarding.
Additionally, taking steps to prevent falls in older adults can reduce the risk of numerous injuries, including fractures. In various types of jobs, ensuring safe work conditions is equally important. This includes using safety mechanisms to keep arms and hands free from machinery with moving parts to avoid crushing injuries.
Lastly, having proper worker’s compensation policies in place and maintaining open lines of communication can improve early intervention and care in workplace settings, thus preventing further complications due to these injuries.
