Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. While many Phalangeal fractures can be treated non-operatively, some do require surgery.
- See: Phalangeal Injury Menu: - Discussion: - fractures of the proximal phalanx are potentially the most disabling fractures in the hand; - direct blows tend to cause transverse or comminuted frx, where as twisting injury may cause oblique or spiral fracture; - proximal fragments are usually flexed by intrinsics while distal fragments are extended due to extrinsic compressive forces; Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. It ossifies from one center that appears during the sixth month of intrauterine life. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. One of the most common foot fractures in children, Open fractures require irrigation & debridement, Nail-bed injuries involving the germinal matrix should be repaired, Displaced intra-articular fractures of the hallux require reduction. This joint sits between the proximal phalanx and a bone in the hand . In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. Adjacent metatarsals should be examined, and neurovascular status should be assessed. Clin OrthopRelat Res, 2005(432): p. 107-15. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint.
Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. Foot fractures are among the most common foot injuries evaluated by primary care physicians. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out! Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. If the wound communicates with the fracture site, the patient should be referred. This is called a "stress fracture.". Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit.
Repeat radiography is indicated and should be obtained one week post-fracture if there was intra-articular involvement or if a reduction was required. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Patients with lesser toe fractures with angulation of more than 20 in the dorsoplantar plane, more than 10 in the mediolateral plane, or more than 20 rotational deformity should also be referred.6,23,24. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. The fifth metatarsal is the long bone on the outside of your foot. Physical examination reveals marked tenderness to palpation. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. Fractures can also develop after repetitive activity, rather than a single injury. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. If there is a break in the skin near the fracture site, the wound should be examined carefully. This procedure is most often done in the doctor's office. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). This content is owned by the AAFP. Surgery may be delayed for several days to allow the swelling in your foot to go down. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. 2017 Oct 01;:1558944717735947. The most common injury in children is a fracture of the neck of the talus. X-rays provide images of dense structures, such as bone. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. Hand (N Y). The proximal phalanx is the phalanx (toe bone) closest to the leg. Ulnar side of hand. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. Fractures of multiple phalanges are common (Figure 3). stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate Proximal phalanx (finger) fracture Contents 1 Background The flexor digitorum superficialis (FDS) inserts at the middle of the phalanx and can cause rotational deformity [1] Extensor tendons and interosseous muscles commonly causes volar angulation [1] Clinical Features Finger pain Differential Diagnosis Hand and Finger Fractures Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). Healing of a broken toe may take 6 to 8 weeks. While on call at the local rural community hospital, you're called by an emergency medicine colleague. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. If it does not, rotational deformity should be suspected. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. The video will appear on the video dashboard once complete. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. And finally, the webinar will cover fixation techniques, including various instrumentation options.Moderator:Jeffrey Lawton, MDChief, Hand and Upper ExtremityProfessor, Orthopaedic SurgeryAssociate Chair for Quality and Safety, Orthopaedic SurgeryProfessor, Plastic SurgeryUniversity of MichiganAnn Arbor, MichiganFaculty: Charles Cassidy, MDHenry H. Banks Professor and ChairmanDepartment of OrthopaedicsTufts Medical CenterBoston, MassachusettsChaitanya Mudgal, MD, MS (Ortho), MChHand Surgery ServiceDepartment of OrthopedicsMassachusetts General HospitalChairman, AO NA Hand Education CommitteeAssociate Professor, Orthopedic Surgery, Harvard Medical SchoolBoston, MassachusettsAmit Gupta, MD, FRCSProfessorDepartment of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyRebecca Neiduski, PhD, OTR/L, CHTDean of the School of Health SciencesProfessor of Health SciencesElon UniversityElon, North Carolina, Ring Finger Proximal Phalanx Fracture in 16M. All material on this website is protected by copyright. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. Note that the volar plate (VP) attachment is involved in the . (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. In children, toe fractures may involve the physis (Figure 2). Joint hyperextension and stress fractures are less common. Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) Most broken toes can be treated without surgery. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. and S. Hacking, Evaluation and management of toe fractures. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. 118(2): p. e273-8. An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. The reduced fracture is splinted with buddy taping. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. Proximal articular. Epidemiology Incidence This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. PMID: 22465516. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. After anesthetizing the toe with ice or a digital block, the physician holds the tip of the toe, applies longitudinal traction, and manipulates the bone fragments into proper position. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days.
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