FINGER DISTAL PHALANX FRACTURES | Hand Surgery Resource

Introduction

Fracture Nomenclature for Finger Distal Phalanx Fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Finger Distal Phalanx, the historical and specifically named fractures include:

Mallet finger fracture

FDP tendon avulsion fracture

DIP joint volar plate avulsion fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Fractures of the distal phalanx are the most common fractures that occur in the hand.^1-3

Definitions

A distal phalanx fracture is a disruption of the mechanical integrity of the distal phalanx.
A distal phalanx fracture produces a discontinuity in the distal phalanx contours that can be complete or incomplete.
A distal phalanx fracture is caused by a direct force that exceeds the breaking point of the bone.
The mechanism of injuries that lead to distal phalanx fractures like falls, sports and motor vehicle accidents are common. But the occurrence of a fracture in a particular human is sporadic. Thus the acronym below is appropriate for systematically describing fractures.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

Universally accepted definitions of clinical fracture stability is not well defined in the hand surgery literature.^4-6
Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting. Most published definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable distal phalanx fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern

Distal phalanx tuft: oblique, transverse, or comminuted
Distal phalanx shaft: transverse, oblique, or comminuted with or without shortening
Distal phalanx base: can involve the distal interphalangeal (DIP) joint; these intra-articular fractures usually involve the dorsal or volar lip of the distal phalanx base

O - Open

Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the distal phalanx require antibiotics with surgical irrigation and wound debridement.^4,7,8

R - Rotation

Distal phalanx fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
Degree of malrotation of the fracture fragments can be used to describe the fracture deformity; this is not a common type of fracture deformity in the distal phalanx.

A - Angulation (fracture fragments in relationship to one another)

Angulation is measured in degrees after identifying the direction of the apex of the angulation
Straight: no angulatory deformity
Angulated: bent at the fracture site
Example: distal phalanx shaft fracture with an angulation of 45° could have the apex of the angulation dorsally or volarly

D - Displacement (Contour)

Displaced: disrupted cortical contours (eg, distal phalanx shaft fractures can be displaced or translated partially or completely)
Nondisplaced: fracture line(s) defining one or several fracture fragment fragments; however, the external cortical contours are not significantly disrupted

I - Intra-articular involvement

Fractures that enter a joint with one or more of their fracture lines.
Distal phalanx fractures can have fragment involvement with the DIP joint.
If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.

C - Closed

Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.^4-6

Distal phalanx fractures: named fractures, fractures with eponyms and other special fractures

Mallet finger fracture

Fracture-dislocation of the DIP joint caused by avulsion of the dorsal lip of the distal phalanx. The mallet finger fracture is usually unstable when >50% of joint is involved.^4,8,9
Patients are typically younger with a history of a sports-related accident.¹⁰
Usually occurs when the tip of the finger is struck with a severe axial load that drives the tip volarly faster than the extensor can relax (eg, when a baseball strikes the fingertip).
The ring finger is the most commonly injured finger.¹⁰
Examination typically shows a swollen and ecchymotic DIP joint with marked dorsal tenderness^4,8,10 and positioned in flexion.
Active ROM exam demonstrates an active extension lag. The collateral ligaments and volar plate are stable.
Flexor digitorum profundus (FDP) tendon function is intact with normal sensation and normal capillary refill.

Imaging

Plain AP and lateral X-rays show the dorsal lip fracture.
The amount of articular surface involvement and degree of volar subluxation of the distal phalanx is best calculated on the lateral X-ray.

Treatment

Splinting the DIP joint in extension is the mainstay of treatment for the majority of mallet finger fractures.^4,8,10
Splinting can be done with an aluminum-padded splint, plaster cast, prefabricated commercial splint, or custom splint.
Most hand surgeons agree that there are 3 mallet finger fracture patterns that always warrant surgical intervention:
- Large dorsal lip fracture fragment representing 25-50% of joint surface; the exact percentage is not well defined
- Dorsal lip fracture associated with volar subluxation of the large distal phalanx fracture fragment
- Dorsal lip fracture fragment that has been pulled proximally over the neck of the middle phalanx
When one of more of these surgical indications is present, reconstructive surgical options include extension block splinting, ORIF with screw, pin, plate, pullout suture or wire.^4,8,10

Complications

Posttraumatic osteoarthritis
Swan neck deformities
Dorsal prominence at the DIP joint

Outcomes

Most patients do well. If the dorsal lip represents ≤1/3, then splinting results are essentially the same as surgical treatment results.
Results are better if treated within 2 weeks.¹¹
No surgical procedure appears to be better than any other.⁸

FDP tendon avulsion fracture

Avulsion of the volar lip of the distal phalanx; also called the "jersey finger" injury.

Imaging

X-ray
Ultrasound

Treatment

Asymptomatic late cases can be left untreated.¹²
Timing is critical for successful repair. Some types require immediate surgery, owing to disruption of the blood supply to the distal tendon;¹³ others can be delayed.¹⁴
Options for late interventions: two-stage tendon graft or fusion of DIP joint if unstable.¹²

Complications

In conservatively managed cases, the necrotic tendon may lead to tenderness in the palm and require excision.
Extension deficit due to flexor tendon advancement during repair
DIP joint stiffness
Operative repair that damages the volar plate may lead to flexion contracture.¹²

Outcomes

In one study, 100% (12/12) patients had satisfactory results after tendon reinsertion; there was a 10–15° extension deficit but good flexion and, in patients treated early, grip strength approached normal values.¹²
Although several repair methods have been developed, none has yet been shown to result in a superior clinical outcome.^15,16

DIP joint volar plate avulsion fracture

A DIP joint volar plate avulsion fracture can occur at the proximal portion of the volar distal phalanx lip without disrupting the insertion of the FDP. This uncommon distal phalanx fracture is associated with dorsal subluxation of the larger distal phalanx fracture fragment.^6&20
This fracture occurs when an axial load is applied to the fingertip while the DIP joint is in slight flexion. This axial loading causes the volar lip of the distal phalanx to be avulsed by the volar plate or a significant comminuted fracture of the distal phalanx lip occurs as the distal phalanx is impacted on the head of the middle phalanx.

Imaging

Plain x-ray imaging will define these fractures very well. Careful attention should be given to the true lateral view.

Treatment

Volar plate avulsion fractures of the distal phalanx that are seen acutely can be reduced and DIP joint stabilized by first obtaining a closed reduction and then securing the reduction with percutaneous pinning of the DIP joint. Splinting alone of the reduced fracture dislocation is unlikely to keep the joint anatomically aligned.
In chronic cases open reduction and internal fixation; open reduction and pinning; dynamic traction; volar plate advancement arthroplasty; and/or DIP joint arthrodesis have all been successfully used to treat this fracture problem successfully.¹⁷

Complications

Distal interphalangeal joint pain
Distal interphalangeal joint stiffness and flexion contracture
Distal interphalangeal joint osteoarthritis
Infection can complicate any open treatment options.

Outcome

When the DIP joint congruity and stability are obtained either acutely or chronic situation by reconstructive surgery then the clinical outcome is usually good to excellent.

Related Anatomy¹⁸

The distal phalanx consists of a distal bony tuft, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the DIP joint with the middle phalanx. The base of the distal phalanx has a dorsal and volar lip.
Ligaments that attached to the distal phalanx include the volar plate of the DIP joint, the radial collateral ligament of the DIP joint and the ulnar collateral ligament of the DIP joint.
Tendon insertions include the insertion of the terminal extensor tendon into the dorsal lip of the distal phalanx and the insertion of the flexor digitorum profundus into the volar proximal third of the distal phalanx.
The distal phalanx and fingertip are further stabilized by fibrous septae in the pulp of the finger and ulnar and radial lateral interosseous ligaments between the base and tuft of the distal phalanx.

Incidence and Related injuries/conditions

The most commonly fractured bone in the human hand is the distal phalanx.^1,3
Distal phalanx fractures are the most commonly occurring hand fracture.
Distal phalanx fractures occur most commonly secondary to sports in younger patients, secondary to labor in middle-aged patients and secondary to falls and motor vehicle accidents in older individuals.⁸
Subungual hematomas are a common related injury.

ICD-10 Codes

DIP VOLAR PLATE AVULSION FRACTURE (Adult)

Diagnostic Guide Name

DIP VOLAR PLATE AVULSION FRACTURE (Adult)

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS	SINGLE CODE ONLY	LEFT	RIGHT	BILATERAL (If Available)
DIP VOLAR PLATE AVULSION FRACTURE (Adult)
- INDEX		S63.431_	S63.430_
- MIDDLE		S63.433_	S63.432_
- RING		S63.435_	S63.434_
- LITTLE		S63.437_	S63.436_
- THUMB (OTHER SPECIFIED INJURY)		S69.82X_	S69.81X_

Instructions (ICD 10 CM 2020, U.S. Version)

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69

A - Initial Encounter

D - Subsequent Routine Healing

S - Sequela

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams

$Comminuted non-displaced distal phalanx tuft fracture$
Comminuted non-displaced distal phalanx tuft fracture
$Non-displaced distal phalanx shaft fracture with small butterfly fragment$
Non-displaced distal phalanx shaft fracture with small butterfly fragment
$Displaced distal phalanx shaft fracture requiring reduction to re-establish support of fingernail matrix.$
Displaced distal phalanx shaft fracture requiring reduction to re-establish support of fingernail matrix.
$Non-displaced mallet fracture of the distal phalanx$
Non-displaced mallet fracture of the distal phalanx
$Minimally displaced mallet fracture of the distal phalanx$
Minimally displaced mallet fracture of the distal phalanx
$Markedly displaced mallet fracture of the distal phalanx that requires reduction and pinning$
Markedly displaced mallet fracture of the distal phalanx that requires reduction and pinning
$Moderately displaced flexor digitorum profundus avulsion fracture$
Moderately displaced flexor digitorum profundus avulsion fracture

Symptoms

Finger trauma

Pain, swelling and ecchymosis of the fingertip

Subungual pain (hematoma)

Pain, swelling and ecchymosis of the finger tip

Finger tip deformity after injury

Typical History

A classic patient with a distal phalanx fracture is a 41-year-old, right-handed male carpenter who strikes his left index finger with a hammer while trying to hammer a nail. The resultant common injury is a tuft fracture of the left index finger with an associated subungual hematoma.

Positive Tests, Exams or Signs

Work-up Options

Images (X-Ray, MRI, etc.)

$Distal phalanx tuft fracture (arrow) lateral view$
Distal phalanx tuft fracture (arrow) lateral view
$Distal phalanx tuft fracture (arrow) AP view$
Distal phalanx tuft fracture (arrow) AP view
$Distal phalanx shaft fracture (arrow) AP & Lat with dorsal apex$
Distal phalanx shaft fracture (arrow) AP & Lat with dorsal apex
$Mallet Finger Fracture with distal fragment subluxation. This fracture will require surgical treatment.$
Mallet Finger Fracture with distal fragment subluxation. This fracture will require surgical treatment.
$Distal phalanx volar plate avulsion fracture (FDP insertion intact) Note the dorsal subluxation of the larger fragment.$
Distal phalanx volar plate avulsion fracture (FDP insertion intact) Note the dorsal subluxation of the larger fragment.
$Distal phalanx base fracture in 94 y.o. female complicated by a malunion after Stack splint treatment.$
Distal phalanx base fracture in 94 y.o. female complicated by a malunion after Stack splint treatment.

Treatment Options

Treatment Goals

When treating closed distal phalanx fractures, the treating surgeon has 4 basic goals:^4,8
1. A finger with a normal appearance. The X-ray may not need to be perfect but the finger should have no obvious deformity (ie, the finger looks normal!)
2. Avoid finger stiffness by maintaining a normal functional ROM (ie, the finger works!)
3. The finger is not painful ( ie, the finger does not hurt!)
4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the joint does not develop early post-traumatic arthritis!
5. Fracture care for open fractures should minimize the risk for infection and osteomyelitis.

Conservative

Most distal phalanx fractures can be treated without surgical treatment.⁸
The typical closed, nondisplaced, minimally angulated, distal phalanx fracture without significant malrotation can be managed in an aluminum plaster or fiberglass or custom splint.
Distal phalanx fractures usually do not require that the finger be included in a short-arm cast.
Even distal phalanx fractures that require a reduction to correct fracture-related deformity usually can be held in anatomic or near-anatomic alignment with a splint without internal or external surgical fixation.

Operative

Surgical treatment of distal phalanx fractures must always be an individualized therapeutic decision. However, surgical distal phalanx fracture care is most frequently recommended when:
1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
2. There is a significantly displaced base of distal phalanx fracture involving the DIP joint, surgical fracture care may be required (eg, displaced mallet finger distal phalanx fractures, FDP avulsion fractures, and/or large volar plate avulsion fractures).
3. Open distal phalanx fractures require surgical care in the form of irrigation and debridement to prevent chronic infection.

Treatment Photos and Diagrams

$Distal phalanx fracture treated in Stack splint with correction of angulation and healing at 8 weeks.$
Distal phalanx fracture treated in Stack splint with correction of angulation and healing at 8 weeks.
Mallet Finger Fracture with severe subluxation undergoing reduction with mini-fluoroscopy and percutaneous extension block pinning.
Mallet Finger Fracture (AP&Lat) after reduction and extension block pinning
Mallet Finger Fracture at arrow (AP&Lat) after healing and pin removal
Distal phalanx Volar Plate Avulsion Fracture post ORIF & pinning
Distal phalanx Volar Plate Avulsion Fracture post ORIF & pinning
Distal phalanx Volar Plate Avulsion Fracture post ORIF & pinning
Distal phalanx Volar Plate Avulsion Fracture post pin removal with intact active flexion

CPT Codes for Treatment Options

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Common Procedure Name

ORIF proximal phalanx

CPT Description

Open treatment phalangeal shaft fracture proximal/mid finger/thumb w/wo fixation each

CPT Code Number

26735

CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Hand Therapy

Post-treatment Management

The care and precautions related to immobilization devices for the distal phalanx fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive splint tightness are red flags and should be reported to the surgeon or his team.
Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
Joints that are splinted for closed stable fractures are usually immobilized.
Fractures that require internal fixation can be mobilized after 4 weeks.
Patients should be instructed to carefully exercise all joints in the injured hand that do not require immobilization. Patients usually can exercise on their own; however, signs of generalized finger or hand stiffness are indications for referral to hand therapy (PT or OT).

Complications

Finger stiffness is the most common complication of hand fractures,^4,8 but distal phalanx fractures usually can be immobilized rapidly enough to avoid this.
Malunion and fingertip deformity after distal phalanx fractures is rare but can occur, especially in open, severe, unstable fractures.¹⁹
Posttraumatic osteoarthritis (photo) can occur in the DIP joint after distal phalanx fractures (eg, large displaced mallet finger fracture).
Chronic osteomyelitis of the distal phalanx is rare but can occur in open distal phalanx fractures, especially in patients with diabetes or in patients whose immune system is compromised.

Outcomes

Most outcomes after distal phalanx fractures are very good.^4,8,20 Fortunately, the complications noted above are very rare. Significant stiffness can usually be avoided because metacarpophalangeal (MP) and PIP joints of the injured finger can be mobilized while the DIP joint and distal phalanx are splinted.

Key Educational Points

Finger fractures must be immobilized before radiographic fracture healing is complete to avoid disabling finger stiffness.
Immobilization of finger fractures for >4 weeks is rarely needed.¹
Today, as in ancient times, finger fractures can usually be treated without surgery.^1,6
Underlying pathological conditions such as bone tumor and osteoporosis should be expected in fractures that occur from trivial trauma. See the diagnostic guide for Enchondroma.
Functional needs of each patient must be considered when recommending treatment for finger fractures.

References

New and Cited Articles

Day CS. Fractures of the Metacarpals and Phalanges. In: Green DP, ed. Green's Operative Hand Surgery. Seventh ed. Philadelphia: Elsevier:231-77.
Harness NG, Meals RA. The history of fracture fixation of the hand and wrist. Clin Orthop Relat Res 2006;445:19-29. PMID: 16505723
Karl JW, Olson PR, Rosenwasser MP. The Epidemiology of Upper Extremity Fractures in the United States, 2009. J Orthop Trauma 2015;29:e242-4. PMID: 25714441
Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (NY) 2017;12:119-26. PMID: 28344521
Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
Husain SN, Dietz JF, Kalainov DM, Lautenschlager EP. A biomechanical study of distal interphalangeal joint subluxation after mallet fracture injury. J Hand Surg Am 2008;33:26-30. PMID: 18261661
Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. Extension block pinning for large mallet fractures. J Hand Surg Am 2003;28:453-9. PMID: 12772104
Shah CM, Sommerkamp TG. Fracture dislocation of the finger joints. J Hand Surg Am 2014;39:792-802. PMID: 24679912
Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. J Hand Surg Am 1977;2:66-9. PMID: 839056
Leversedge FJ, Ditsios K, Goldfarb CA, Silva MJ, Gelberman RH, Boyer MI. Vascular anatomy of the human flexor digitorum profundus tendon insertion. J Hand Surg Am 2002;27:806-12. PMID: 12239668
Al-Qattan MM. Type 5 avulsion of the insertion of the flexor digitorum profundus tendon. J Hand Surg Br 2001;26:427-31. PMID: 11560423
Huq S, George S, Boyce DE. Zone 1 flexor tendon injuries: a review of the current treatment options for acute injuries. J Plast Reconstr Aesthet Surg 2013;66:1023-31. PMID: 23672773
Ruchelsman DE, Christoforou D, Wasserman B, Lee SK, Rettig ME. Avulsion injuries of the flexor digitorum profundus tendon. J Am Acad Orthop Surg 2011;19:152-62. PMID: 21368096
Rettig ME, Dassa G, Raskin KB. Volar plate arthroplasty of the distal interphalangeal joint. J Hand Surg Am 2001;26:940-4. PMID: 11561249
Slattery D, Aland R, Durbridge G, Cowin G. Dorsal digital septum of the distal interphalangeal joint. J Hand Surg Am 2009;34:467-73. PMID: 19258144
Kaplan SJ. Bony complications caused by stack splints. J Hand Surg Am 2013;38:2305-6. PMID: 24207001
Yoon JO, Baek H, Kim JK. The Outcomes of Extension Block Pinning and Nonsurgical Management for Mallet Fracture. J Hand Surg Am 2017;42:387 e1- e7. PMID: 28274605

Reviews

Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-22. PMID: 27113910

Classics

Wehbé MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am 1984;66(5):658-69. PMID: 6725314
Schneider LH. Fractures of the distal interphalangeal joint. Hand Clin 1994;10:277-285. PMID: 8040206

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