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FINGER MIDDLE PHALANX ADULT

Introduction

Fracture Nomenclature for Finger Middle Phalanx Adult

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 Middle Phalanx Adult, the historical and specifically named fractures include:

Fracture-dislocation PIP Joint

Middle Phalanx volar plate avulsion fracture without dislocation

Middle Phalanx Base Pilon 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 middle phalanx occur less frequently than distal and proximal phalangeal fractures, and they represent some of the least common of all hand fractures. The most prevalent middle phalanx fractures are proximal interphalangeal (PIP) joint avulsion fractures, followed by transverse fractures, and the most common causes are sports-related injuries and machinery accidents.  Treating and restoring range of motion (ROM) and function is far more challenging in middle phalanx fractures than it is for distal and proximal phalanges, primarily due to its complex anatomy and the intimate relationship between the flexor and extensor tendons with the bone.1,2

Definitions

  • A middle phalanx fracture is a disruption of the mechanical integrity of the middle phalanx.
  • A middle phalanx fracture produces a discontinuity in the middle phalanx contours that can be complete or incomplete.
  • A middle phalanx fracture is caused by a direct force that exceeds the breaking point of the bone.  

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.3-5
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained with simple splinting. However, most 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 ROM.
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable middle phalanx fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern

  • Middle phalanx: oblique, transverse, or comminuted
  • Middle phalanx shaft: transverse, oblique, or comminuted with or without shortening
  • Middle phalanx base: can involve the PIP joint; these intra-articular fractures usually involve the dorsal or volar lip of the middle phalanx base; large comminuted or displaced fracture fragments will disrupt the congruity of the joint.
  • Middle phalanx head: can involve the DIP joint; in these intra-articular fractures, usually one or both condyles of the middle phalanx head with or without displacement; displaced fractures can affect joint congruity.

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 middle phalanx require antibiotics with surgical irrigation and wound debridement.3,6,7

R - Rotation

  • Middle phalanx fracture deformity can be caused by rotation of the distal fragment or the proximal fragment. Significant malrotation can affect the position of fingertip during grip.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity

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: middle phalanx shaft fractures tend to displace with an apex volar angulation as a result of the pull of adjacent tendon attachments.8 The flexor digitorum superficialis pulls the proximal fragment volarly, while the extensor pulls the distal fragment dorsally.

D - Displacement (Contour)

  • Displaced: disrupted cortical contours (eg, middle phalanx shaft fractures are often displaced and rotated due to their flexor tendons2
  • Nondisplaced: fracture line(s) are visible and define one or several fracture fragment fragments; however, the external cortical contours are not significantly disrupted, and no fragment displacement is presented

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Middle phalanx fractures can have fragment involvement with the DIP or PIP joints.
  • 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.
  • Fractures at the middle phalanx base are often intra-articular and frequently require surgical treatment.9
  • Articular fractures of the middle phalanx include condylar fractures, comminuted intra-articular fractures, dorsal, volar or lateral base fractures, fracture-dislocations, impacted fractures of the base of the middle phalanx, and shaft fractures involving the joint.10

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.3-5

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

Fracture-dislocation PIP Joint

Middle phalanx volar lip fractures are the most common form of osseous injury associated with PIP joint fracture-dislocations.11

  • These injuries are generally classified as either dorsal or volar fracture-dislocations of the PIP joint.9
    • The amount, direction, and location of the causative force, the position of the PIP joint, and the tension of the intrinsic ligaments and extrinsic muscles determine the extent and type of fracture of the base of the middle phalanx.9
    • These injuries are often problematic due to the importance of the PIP joint for general hand function. If too much of the volar base is detached, the collateral ligaments may no longer be able to prevent the middle phalanx from moving dorsally.7
    • Volar dislocations of the PIP joint are uncommon and represent disruption of the central slip of the extensor apparatus from the dorsal base of the middle phalanx.12
    • Dorsal fracture-dislocations of the PIP joint with volar articular defects of more than 60% have been found to be unstable, while stability is variable with 40% involvement and stable with 20% involvement or less.3

Imaging

  • Plain AP and true lateral X-ray views are needed.
  • The X-ray will help to distinguish avulsion chip fractures from fracture-dislocations with significant PIP joint involvement.

Treatment

  • Surgery may be needed for PIP joint fracture-dislocations, but both conservative and surgical treatments should aim to achieve and maintain complete reduction of the dislocation and restore enough stability to allow early movement.
    • Several anatomical structures may also need reconstruction, including the collateral ligament, volar plate, or attachment of the central slip.9
    • Closed reduction and immobilization in slight flexion with a dorsal splint for two weeks is indicated as the first line of treatment, if this maintains PIP reduction.
    • Prompt and accurate reduction will help to produce satisfactory results, but open reduction of the articular surface may be needed if two reduction attempts fail.
    • When a PIP reduction is obtained, an active motion test or at least a passive motion test should be performed to see if the reduction is stable through a normal arc of PIP motion. Unstable PIP fracture dislocations require more surgical intervention and more complex control rehabilitation to achieve a functional ROM without loss of joint reduction.
    • Internal fixation may also be needed in some cases with bone grafting rarely needed.9
  • Extension block splinting is indicated for dorsal fracture-dislocations if <40% of the joint involved and it is stable.
  • if the injury leads to PIP joint instability, dorsal fracture-dislocations typically require surgery such as (ORIF) or hemihamate arthroplasty. The hemi-handmade arthroplasty is excellent option for treating unstable comminuted dorsal PIP joint fracture-dislocations.  This procedure is usually indicated when 50% or more of the volar middle phalanx is fractured, thus producing an unstable dislocation. This procedure was first described by Hastings at the 1999 American Society for Surgery the Hand annual meeting. This procedure is done through a volar approach to the PIP joint. A “V” or zigzag incision is made in the skin, the flaps mobilized, the neurovascular structures identified and protected, and the flexor tendon sheath visualized. The A3 pulley is opened, if not already opened by the injury. The A2 and A4 pulleys are preserved. The flexor tendons are retracted exposing the volar plate and more distally the volar fracture in the middle phalanx. This is followed by releasing the attachments of the volar plate to the accessory collateral ligaments. This release allows the volar plate to be folded back proximally, thus exposing the rest of the middle phalanx fracture site. Fragments of bone and articular surface that are attached to the plate are removed. Next, the collateral ligaments are released, and the joint is hyperextended into the “shotgun” position. The defect in the volar middle phalanx’s articular surface is assessed. A rongeur or small saw is used to shape the defect so that it can accommodate a block-shaped osteochondral graft. The defect’s size is measured carefully. The joint is temporary reduced and attention turned to the donor site of the ipsilateral ring, little and hamate joint. After carefully locating the joint, a dorsal incision is made to expose the joint while simultaneously protecting the extensor tendon and the dorsal ulnar sensory nerve. At the ring, little, and hamate joint level the periosteal and capsular flaps are raised to allow visualization of the joint and the dorsal hamate. Next, a block-shaped graft centered on the apex of the hamate at the joint between the ring and little metacarpals is marked and carefully measured. The block graph should be slightly larger than the measured defect in the base of the middle phalanx. The longitudinal hamate cuts are made first. The proximal transfer osteotomy in the hamate is then performed.  The final cut is made with the appropriately sized curved osteotome. Some surgeons start proximally through a notch in the proximal hamate, while other surgeons start distally with or without removing a portion of the ring and little metacarpal bases. Do not make the graph too thin, do not fragment the graft, and do not damage the articular surface of the hamate or the metacarpals. Once harvested, the block graft is brought to the finger and placed in the middle phalanx defect. It is temporarily held in place with a small K-wire. The surgeon should align the articular surface anatomically and tilt the graft to assure a cup -shaped surface of the middle phalanx base as visualized from the lateral aspect of the PIP joint. Note, the cartilage of the hamate is often thicker than the cartilage of the middle phalanx which may affect the appearance of the PIP joint on X-Ray. On occasion, adding extra cancellous bone graft from the hamate is needed distally in order to provide the proper tilt of the block-shaped graft and facilitating the curved laterally visualized cup shape of the base of the middle phalanx. Note, morphologic studies have shown this graft is not a perfect match to the volar middle phalanx base but typically variations have not affected the clinical outcome. Secure the graft with two or three 0.9 two 1.5 mm screws through the graft and into the dorsal middle phalanx dorsal cortex. Remove the K wire. Reduce the joint and reattach the volar plate to the stumps of the collateral ligaments left on the base of the middle phalanx. Check the range of motion and the stability. Close the wrist and finger incisions. Splint the PIP joint in 15 to 20 degrees of flexion. Start post-operative range of motion exercises at 7 to 10 days.23-27 For more information on hemihamate arthroplasty see the surgical images below and the links to HAND.E.
  •  Other options include volar plate arthroplasty, closed reduction and percutaneous pinning (if >40% of the joint is involved and it is unstable), arthrodesis, and dynamic distraction external fixation.3
  • Volar fracture-dislocations may be treated conservatively with 4-8-weeks of PIP joint extension splinting if <40% of the joint involved and it is stable.12
  • Surgery is needed for volar fracture-dislocations if >40% of the joint involved and it is unstable, and may include ORIF or closed reduction and percutaneous pinning
  • Extensive comminution in PIP fracture-dislocations may complicate treatment and require osteochondral bone grafting.7 In several cases, PIP arthrodesis or arthroplasty may be needed.
  • ORIF with an autologous hemihamate osteoarticular graft may be required for PIP fracture-dislocations in which more than 50% of the base of the middle phalanx is fractured with an intact dorsal cortex.10
  • In athletes with large fracture fragments, open fracture repair with screws and/or K-wires may be necessary to reduce the fracture and achieve PIP joint stability.12
  • After lateral stable PIP fracture-dislocations are reduced, buddy taping should be utilized to facilitate the reacquisition of stability.12

Complications

  • PIP joint pain
  • PIP joint stiffness and contractures
  • Post-traumatic osteoarthritis
  • Swan neck deformity
  • Infection can complicate any open treatment option
  • Note that potential complications of the hemi-hamate arthroplasty include :
  • Decrease range of motion
  • Decreased grip strength
  • Infection
  • Osteoarthritis
  • Graft fragmentation or failure
  • Non-union
  • Recurrent subluxation or dislocation
  • A2 and/or A4 pulley damage 
  • Secondary surgical treatment for persistent sympotms

Note that potential complications of the hemi-hamate arthroplasty include :

  • Decrease range of motion
  • Decreased grip strength
  • Infection
  • Osteoarthritis
  • Graft fragmentation or failure
  • Non-union
  • Recurrent subluxation or dislocation
  • A2 and/or A4 pulley damage
  • Secondary surgical treatment for persistent symptoms

Outcomes

  • Although several surgical options exist for PIP joint fracture-dislocations, no single approach appears to be superior.7
  • The volar mini-plate and screw technique has been found to elicit satisfactory short-term results.7
  • The hemi-hamate autograft and screw fixation procedure has been associated with satisfactory results in 13 patients with PIP joint fracture-dislocations.10

For ASSH's Hand-e Surgical Video of ORIF PIPJ fracture dislocation through a volar approach by Tuckman:

For ASSH's Hand-e Surgical Video of Hemi-hamate reconstruction of PIPJ fracture dislocation by Izadi:

Middle Phalanx volar plate avulsion fracture without dislocation

  • Avulsion fractures of the dorsal base of the middle phalanx represent detachment of the insertion of the central tendon, which can result from an anterior PIP joint dislocation.10
  • Volar plate avulsion fractures of the PIP joint usually occur due to passive hyperextension or a dorsal dislocation, and they most often involve only a small fragment of the middle phalangeal base avulsed by the detached volar plate.9,13
  • Lateral intra-articular middle phalanx fractures are usually ligamentous avulsion fractures.13

Imaging

  • Plain AP and lateral X-ray views are needed.

Treatment

  • Dorsal lip avulsion fractures of the middle phalanx caused by the central slip bony avulsions can be treated with closed reduction and dynamic extension splinting of the PIP joint. If closed reduction fails, operative fixation of the fracture fragment or tendon reinsertion should be considered.13
  • Volar plate avulsion fractures can be treated conservatively with buddy taping or dorsal block splinting if there is no potential for redislocation.12,13
    • Active ROM exercises should be initiated early to minimize stiffness and edema.13
    • If the fracture fragment involves more than 40% of the articular surface, instability of the joint can result, and protective dorsal extension block splinting or surgery may be needed in these cases to maintain PIP joint stability. Surgical options include volar plate arthroplasty, ORIF, closed reduction with K-wire fixation, extension block pinning, open fracture repair, and hemihamate autografting procedures.12,13
  • If the dorsal avulsed fragment is displaced more than 2 mm, accurate reduction and internal or percutaneous pin fixation are necessary to prevent extensor lag and subsequent boutonnière deformity.10
  • Another surgical option for chronic volar plate avulsion fractures is the “volar plate arthroplasty,” in which the volar plate is detached from the middle phalanx, but its soft-tissue attachment to the bone in the volar aspect of the proximal and middle phalanges is maintained, and the distal edge of the volar plate is advanced into the defect in the middle phalanx volar lip. Before advancing the volar plate, the fracture fragment is removed.14
  • Buddy taping and early ROM are recommended for lateral middle phalanx avulsion fractures unless there is unacceptable joint incongruity.13

Complications

  • Infection
  • PIP joint stiffness and flexion contracture
  • PIP joint pain
  • PIP joint instability

Outcomes

  • The “volar plate arthroplasty” has led to significant improvements in ROM, pain, and overall function, and may be considered a respectable option for chronic volar plate avulsion fractures.14

Middle Phalanx Base Pilon fracture

  • The term “pilon fracture” is used to describe comminuted articular fractures at the base of the middle phalanx where part of the articular surface of the middle phalanx at the PIP joint is driven into the proximal metaphysis of the base of the middle phalanx.10
  • A pilon fracture results from an axial load that causes central articular depression and variable splay of the dorsal/volar and radial/ulnar margins of the bone.10,15
  • Disruption in the continuity of the palmar restraints of the collateral ligaments and palmar plate complex with the bony buttress provided by the palmar lip of the middle phalanx base allow dorsal subluxation.15

Imaging

  • X-ray

Treatment

  • Treating pilon fractures is an ongoing and challenging problem, and consensus is still lacking as to the best treatment approach.
    • Conservative options include immobilization and splinting.10,15
    • Surgical options include ORIF, skeletal traction through the middle phalanx, and distraction dynamic external fixation (DDEF).10,15
    • ORIF is often a technically difficult procedure because of comminution of the bone fragments; stiffness is a common problem, and there is a need for bone grafting.10
    • The hemihamate autograft procedure is also precluded because the dorsal cortex is usually fractured.10

Complications

  • Infection
  • Pain
  • Stiffness
  • Instability
  • Posttraumatic osteoarthritis

Outcomes

  • Immobilization and splinting alone have both produced poor outcomes in terms of stiffness, pain, and markedly reduced ROM.10
  • Traction and ORIF have led to similar results, and neither was able to accomplish anatomic articular restoration or help patients regain full mobility.10
  • Dynamic distraction external fixation (DDEF) has been found to elicit positive outcomes, helping to maintain reduction and restore digital ROM. Early return to work, good pain relief, and high level of patient satisfaction have also been achieved through this procedure, but it is technically demanding and requires significant hand therapy.15

Related Anatomy

  • The middle phalanx consists of a distal phalangeal head that articulates at the distal interphalangeal (DIP) joint with the distal phalanx, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the PIP joint with the proximal phalanx. The base of the middle phalanx has a dorsal and volar lip.
  • The ligaments associated with the middle phalanx at the DIP and PIP joints are the dorsal capsule, the collateral ligaments (proper and accessory collaterals), and the volar plates.  The retinacular ligament that runs obliquely along the middle phalanx is the final ligament associated with the middle phalanx.
  • Tendon attachments include the flexor digitorum superficialis tendon, which is inserted by two slips on either side of the base of the middle phalanx and the extensor tendons. The central slip inserts into the dorsal lip of the base of the middle phalanx, and the terminal extensor tendon traverses the middle phalanx and then inserts into the distal phalanx. The median band of the extensor digitorum tendon passes to the base of the middle phalanx.
  • There is a basic anatomical difference between the proximal and middle phalanges: the proximal phalanges have a longer, wider intramedullary canal with more cancellous bone, whereas the middle phalanges have a shorter, narrower intramedullary canal with more cortical bone.16 In general, fractures through cortical bone heal slower than fractures in cancellous bone.

Incidence and Related injuries/conditions

  • Metacarpal and phalangeal fractures account for nearly half of all hand injuries that present to the emergency room.15
  • Fractures of the middle phalanx are relatively uncommon. Literature reporting their incidence is sparse, but it is approximated that only 10% of all phalangeal fractures occur in the middle phalanx.8
  • Phalangeal fractures account for 23% of all below-elbow fractures.18
    • Unstable fracture-dislocations of the PIP joint have an estimated annual incidence of 9 per 100,000.11
  • Published statistics on the incidence of distal and middle phalanx fractures compared with all fractures of the hand are also scarce.1
  • While spiral and oblique fractures of the shaft are more common in the proximal phalanx, transverse fractures tend to be more common in the middle phalanx.10
ICD-10 Codes

  • FINGER MIDDLE PHALANX

    Diagnostic Guide Name

    FINGER MIDDLE PHALANX

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

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (IF AVAILABLE)
    INDEX MIDDLE PHALANX    
    - DISPLACED S62.621_S62.620_ 
    - NONDISPLACED S62.651_S62.650_ 
    MIDDLE MIDDLE PHALANX    
    - DISPLACED S62.623_S62.622_ 
    - NONDISPLACED S62.653_S62.652_ 
    RING MIDDLE PHALANX    
    - DISPLACED S62.625_S62.624_ 
    - NONDISPLACED S62.655_S62.654_ 
    LITTLE MIDDLE PHALANX    
    - DISPLACED S62.627_S62.626_ 
    - NONDISPLACED S62.657_S62.656_ 

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

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    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
  • Non-displaced middle phalanx neck fracture
    Non-displaced middle phalanx neck fracture
  • Angulated middle phalanx neck fracture
    Angulated middle phalanx neck fracture
  • Displaced angulated intra-articular middle phalanx condylar fracture
    Displaced angulated intra-articular middle phalanx condylar fracture
  • Non-displaced bicondylar middle phalanx neck fracture
    Non-displaced bicondylar middle phalanx neck fracture
  • Non-displaced middle phalanx shaft fracture
    Non-displaced middle phalanx shaft fracture
  • Non-displaced middle phalanx angulated shaft fracture
    Non-displaced middle phalanx angulated shaft fracture
  • Non-displaced central slip intra-articular middle phalanx base fracture
    Non-displaced central slip intra-articular middle phalanx base fracture
  • Displaced solar plate intra-articular avulsion of the middle phalanx base fracture
    Displaced solar plate intra-articular avulsion of the middle phalanx base fracture
Symptoms
Pain in the injured finger
Swelling in the injured finger
Ecchymosis in the injured finger
Deformity in the injured finger
Loss of motion
Typical History

A classic patient with a middle phalanx fracture is a 36-year-old, right-handed male, who injured his finger while playing a game of recreational football. While running the ball during the game, he extended his right hand to assume the “stiff arm” position, and his hand subsequently came into contact with a defender accelerating his way rapidly. This incident hyperextended his right middle finger and led to an avulsion fracture of its PIP joint, which resulted in subsequent pain, stiffness, and swelling.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
X-rays Middle Phalanx Fractures
  • Comminuted minimally displaced closed right long finger middle phalanx fracture
    Comminuted minimally displaced closed right long finger middle phalanx fracture
  • Central slip avulsion fracture (arrow) Lateral, AP and oblique views
    Central slip avulsion fracture (arrow) Lateral, AP and oblique views
  • Volar plate avulsion fracture with dorsal subluxation
    Volar plate avulsion fracture with dorsal subluxation
  • Central slip avulsion fracture with simultaneous volarly angulated base fracture
    Central slip avulsion fracture with simultaneous volarly angulated base fracture
  • Middle phalanx displaced intra-articular radial condyle fracture
    Middle phalanx displaced intra-articular radial condyle fracture
  • Comminuted intra-articular middle phalanx fracture after ORIF
    Comminuted intra-articular middle phalanx fracture after ORIF
  • Open right ring middle phalanx shaft fracture
    Open right ring middle phalanx shaft fracture
Treatment Options
Treatment Goals
  • When treating closed middle phalanx fractures, the treating surgeon has 4 basic goals:3,7
    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 middle phalanx fractures can be treated without surgical treatment.7
  • The typical closed, nondisplaced, minimally angulated, middle phalanx fracture without significant malrotation can be managed in an aluminum, plaster, fiberglass, or custom splint.
  • Middle phalanx fractures usually do not require that the finger be included in a short-arm cast.
  • Even middle 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.
  • Middle phalanx head fractures can usually be treated successfully with closed reduction and splinting if they are anatomically aligned.8
Operative
  • Surgical treatment of middle phalanx fractures must always be an individualized therapeutic decision. However, surgical middle 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 middle phalanx fracture involving the PIP joint, surgical fracture care may be required (eg, displaced PIP joint fracture-dislocations and avulsion fractures).
    3. Open middle phalanx fractures require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Most displaced fractures of the middle phalanx head and pilon fracture also require surgical intervention.10,15  Displaced closed acute head fractures of the middle phalanx condyles usually can be closed reduced and internally fixed with percutaneous pins.
  • Surgical options for middle phalanx shaft fractures in which closed reduction fails include axial pinning, transfixion pinning, tension band wiring, and fixation using an external fixator.2

Post-treatment Management:

  • The care and precautions related to immobilization devices for the middle 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.
  • The amount of time needed for complete bony healing of middle phalanx shaft fractures is typically 5 months, although most patients can return to work in about 4-6 weeks.10
  • If an infection does occur, management should focus on eradicating sepsis with thorough debridement, appropriate antibiotics (eg, cephalosporin, penicillin), and fracture stabilization, followed by obtaining fracture union and regaining a functional extremity.10
  • 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).
Treatment Photos and Diagrams
Middle Phalanx Fracture Treatment
  • Volar plate avulsion fracture with dorsal subluxation
    Volar plate avulsion fracture with dorsal subluxation
  • Exposure for ORIF - double arrows on fragment & cartilage of middle phalanx and single arrow on shaft fracture surface
    Exposure for ORIF - double arrows on fragment & cartilage of middle phalanx and single arrow on shaft fracture surface
  • Arrow on temporary fixation K-wire in fracture fragment
    Arrow on temporary fixation K-wire in fracture fragment
  • Fracture clamp holding reduction
    Fracture clamp holding reduction
  • Temporary fixation with K-wire of fracture fragment
    Temporary fixation with K-wire of fracture fragment
  • ORIF completed with 2 screws
    ORIF completed with 2 screws
  • Open middle phalanx shaft fracture with minimal bone loss
    Open middle phalanx shaft fracture with minimal bone loss
  • Pinned open middle phalanx shaft fracture
    Pinned open middle phalanx shaft fracture
  • Healed open middle phalanx shaft fracture
    Healed open middle phalanx shaft fracture
Middle Phalanx Fracture Treatment: Hemi-Hamate
  • Note the volar plate avulsion fracture of the right ring finger with comminution of the fracture fragment and involvement of 50% or more of the joint surface.
    Note the volar plate avulsion fracture of the right ring finger with comminution of the fracture fragment and involvement of 50% or more of the joint surface.
  • The right ring finger PIP joint has been exposed through a volar incision, the flexor sheath opened, the flexor tendons displaced, and the collateral ligaments released. The finger is now in the “shotgun” position. Note the arrow showing the intact dorsal cartilage of the middle phalanx. The volar cartilage is missing after removal of the fracture fragments.
    The right ring finger PIP joint has been exposed through a volar incision, the flexor sheath opened, the flexor tendons displaced, and the collateral ligaments released. The finger is now in the “shotgun” position. Note the arrow showing the intact dorsal cartilage of the middle phalanx. The volar cartilage is missing after removal of the fracture fragments.
  • The little metacarpal (1), ring metacarpal (2) and hamate (3) joints have been exposed through a dorsal incision.
    The little metacarpal (1), ring metacarpal (2) and hamate (3) joints have been exposed through a dorsal incision.
  • This diagram shows the area of damage in the base of the ring middle phalanx (A), the graft donor site (B), the lateral view of the middle phalanx with missing fracture fragments and articular cartilage (C) and the lateral view of the middle phalanx with the graft (D) in place prior to internal fixation with small screws.
    This diagram shows the area of damage in the base of the ring middle phalanx (A), the graft donor site (B), the lateral view of the middle phalanx with missing fracture fragments and articular cartilage (C) and the lateral view of the middle phalanx with the graft (D) in place prior to internal fixation with small screws.
  • Note the harvested graft from the hamate with the 5th metacarpal facet (5), the apex of cartilage between the facets (A) and the 4th metacarpal facet (4). Note the graft was been intentionally harvested to be slightly bigger than the measured defect in the base of the middle phalanx. This will allow contouring of the graft.
    Note the harvested graft from the hamate with the 5th metacarpal facet (5), the apex of cartilage between the facets (A) and the 4th metacarpal facet (4). Note the graft was been intentionally harvested to be slightly bigger than the measured defect in the base of the middle phalanx. This will allow contouring of the graft.
  • AP X Ray of the finger after internal fixation of the hemi-hamate graft.
    AP X Ray of the finger after internal fixation of the hemi-hamate graft.
  • Lateral X Ray of the finger after internal fixation of the hemi-hamate graft.
    Lateral X Ray of the finger after internal fixation of the hemi-hamate graft.
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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Complications
  • Finger stiffness is the most common complication of hand fractures,3,7 but middle phalanx fractures usually can be immobilized rapidly enough to avoid this.
  • Malunion and fingertip deformity after middle phalanx fractures is rare but can occur, especially in open, severe, unstable fractures.19 Malunions with malrotation can occur.
  • Posttraumatic osteoarthritis can occur in the PIP joint after some middle phalanx fractures (eg, PIP joint fracture-dislocations, pilon fractures).
  • Chronic osteomyelitis of the middle phalanx is rare but can occur in open middle phalanx fractures, especially in patients with diabetes or in patients whose immune system is compromised.
    • Established phalangeal osteomyelitis is extremely difficult to eradicate, and even after surgery, the final result is often a painful, stiff, useless digit. Amputation may therefore be considered under such circumstances.10
  • Other possible complications of middle phalanx fractures include nonunion or delayed union, loss of motion, PIP extensor lag, and flexor tendon rupture or entrapment.10
Outcomes
  • Most outcomes after middle phalanx fractures are very good.3,7,,20 Fortunately, the complications noted above are very rare. Significant stiffness can usually be avoided because metacarpophalangeal (MP) and DIP joints of the injured finger can be mobilized while the PIP joint and middle phalanx are splinted. 
  • A satisfactory treatment rate of 92-94% has been reported with closed reduction and casting or splinting for phalangeal shaft fractures.10
  • Closed reduction and percutaneous pin fixation has been associated with better functional outcomes than ORIF for fractures of the head of the middle phalanx, ie, condylar fractures).8
  • Several studies have reported that managing middle phalanx fractures with plates and screws has yielded poor functional outcomes.16
Video
Percutaneous pinning of displace right ring middle phalanx intra-articular condyle fracture
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.10
  • Today, as in ancient times, finger fractures can usually be treated without surgery.5,10
  • Underlying pathological conditions such as a bone tumor (eg, enchondroma) and osteoporosis should be expected in fractures that occur from trivial trauma.
  • Functional needs of each patient must be considered when recommending treatment for finger fractures.
  • Care should be taken when performing surgical fixation to avoid shortening the middle phalanx, which may result in imbalance of the extensor mechanism and subsequent extensor lag.8
  • Anatomical fixation of middle phalanx fractures with screws—with or without plates—is fraught with problems, as the intra- and postoperative disturbance of the closely aligned extensor tendon mechanism often leads to stiffness.7
  • It is more challenging to restore ROM and function in fractures of the middle phalanx than it is in distal and proximal phalangeal fractures, primarily due to the complex anatomy along the middle phalanx.2
References

New and Cited Articles
 

Cannon NM.  Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003;16(2):105-16. PMID: 12755162

  1. Zhang X, Shao X, Zhang Z, et al. Cemented K-wire fixation for the treatment of shaft fractures of middle phalanges. Injury 2017 [Epub]. PMID: 29055495
  2. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  3. 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
  4. 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
  5. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12:119-26. PMID: 28344521
  6. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  7. Paksima N, Johnson J, Brown A, Cohn M. Percutaneous pinning of middle phalangeal neck fractures: surgical technique. J Hand Surg Am 2012;37(9):1913-6. PMID: 22857911
  8. Seno N, Hashizume H, Inoue H, et al. Fractures of the base of the middle phalanx of the finger. Classification, management and long-term results. J Bone Joint Surg Br 1997;79(5):758-63. PMID: 9331031
  9. Day CS. Fractures of the Metacarpals and Phalanges. In: Green DP, ed. Green's Operative Hand Surgery. Seventh ed. Philadelphia: Elsevier:231-77.
  10. Weiss AP. Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clin Orthop Relat Res 1996;(327):21-8. PMID: 8641066
  11. Chen F, Kalainov DM. Phalanx fractures and dislocations in athletes. Curr Rev Musculoskelet Med 2017;10(1):10-16. PMID: 28185123
  12. Carpenter S, Rohde RS. Treatment of phalangeal fractures. Hand Clin 2013;29(4):519-34. PMID: 24209951
  13. Wollstein R, Watson HK, Carlson L. A technique for the repair of chronic volar plate avulsion of the proximal interphalangeal joint: a review of 54 cases. Plast Reconstr Surg 2006;117(4):1239-45; PMID: 16582793
  14. Mansha M, Miranda S. Early results of a simple distraction dynamic external fixator in management of comminuted intra-articular fractures of base of middle phalanx. J Hand Microsurg 2013;5(2):63-7. PMID: 24426677
  15. Dhamangaonkar AC, Patankar HS. Antegrade joint-sparing intramedullary wiring for middle phalanx shaft fractures. J Hand Surg Am 2014;39(8):1517-23. PMID: 24855966
  16. Immerman I, Livermore MS, Szabo RM. Use of emergency department services for hand, wrist, and forearm fractures in the United States in 2008. J Surg Orthop Adv 2014;23(2):98-104. PMID: 24875340
  17. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908-15. PMID: 11561245
  18. Kaplan SJ. Bony complications caused by stack splints. J Hand Surg Am 2013;38:2305-6. PMID: 24207001
  19. Harness NG, Meals RA. The history of fracture fixation of the hand and wrist. Clin Orthop Relat Res 2006;445:19-29. PMID: 16505723
  20. 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
  21. Shah CM, Sommerkamp TG. Fracture dislocation of the finger joints. J Hand Surg Am 2014;39:792-802. PMID: 24679912
  22. Williams RMM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of Unstable Dorsal Proximal Interphalangeal Fracture/Dislocations Using a Hemi-Hamate Autograft. J Hand Surg 2003;28A:856–865.
  23. Drain J, Mehta S, Goyal KS. An Analysis of Hamate Morphology Relevant to Hemi-Hamate Arthroplasty. J Hand Surg Am. 2020;45(7): 657.e1-e6.
  24. McAuliffe JA. Hemi-Hamate Autograft for The Treatment Of Unstable Dorsal Fracture Dislocation of The Proximal Interphalangeal Joint. J Hand Surg Am. 2009;34(10):1890e1894.
  25. Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-Hamate Arthroplasty Provides Functional Reconstruction of Acute and Chronic Proximal Interphalangeal Fracture-Dislocations. J Hand Surg Am. 2009;34(7):1232-1241.
  26. DeNoble PH, Record NC. A Modification to Simplify the Harvest of a Hemi-hamate Autograft. J Hand Surg Am. 2016;41(5): e99ee102.

Reviews

  1. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  2. 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

  1. Roberts N. Fractures of the Phalanges of the Hand and Metacarpals: (Section of Orthopaedics). Proc R Soc Med 1938;31(7):793-8. PMID: 19991521
  2. James JI. Fractures of the proximal and middle phalanges of the fingers. Acta Orthop Scand 1962;32:401-12. PMID: 13957247
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