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Hand Surgery, Vol. 18, No. 2 (2013) 229234 © World Scientific Publishing Company DOI: 10.1142/S0218810413500287
CONSERVATIVE TREATMENT OF FRACTURES OF THE PROXIMAL PHALANX: AN OPTION EVEN FOR UNSTABLE FRACTURE PATTERNS
Hand Surg. 2013.18:229-234. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
Michael Held, Pieter Jordaan, Maritz Laubscher, Martin Singer and Michael Solomons Martin Singer Hand Unit, Orthopaedic Department Groote Schuur Hospital, University of Cape Town, South Africa Received 7 December 2012; Revised 17 February 2013; Accepted 18 February 2013 ABSTRACT Purpose: The purpose of the study was to assess the efficacy of the conservative management of proximal phalangeal fractures in a dorsal plaster slab. Methods: Twenty-three consecutive patients with extra-articular proximal phalangeal fractures were included in this prospective study. Fourteen patients (62%) presented with fractures considered unstable. The fractures were reduced and the position was held with a dorsal plaster slab for three weeks. The patients were followed up for an average of seven weeks (range 2 to 45) after the injury. Range of motion of the finger and radiological evidence of union, non-union or malunion was documented after removal of the plaster. Results: Ninety-one percent of fractures maintained an acceptable reduction. All cases measured less than 15 of angulation. On average 1,1 mm of shortening was measured. In two (9%) cases the reduction was not accepted on follow up assessment and the fractures were managed surgically. Conclusion: Most extra-articular proximal phalanx fractures can be managed conservatively with acceptable results. Keywords: Proximal Phalanx; Complex Finger Fractures; Conservative Management; Unstable Finger Fractures.
INTRODUCTION
worsened by extensor tendon zone IV adherence and shortening at the fracture site.3,5,6 One millimetre of shortening leads to 12 of extensor lag at the PIPJ.3 Multiple treatment protocols and options, ranging from splinting, percutaneous wires, external fixators, interfragmentary screw fixation to mini fragment plates point towards the challenges arising with the management of fractures of the proximal phalanx. The key to acceptable functional results is to achieve a stable reduction with correct alignment and to allow early mobilisation of the digit. The general
Phalangeal fractures are almost twice as common as metacarpal fractures and most occur in the proximal phalanx.13 Fractures usually present with apex volar angulation due to the insertion of the interosseus muscle onto the base of the proximal phalanx, thus flexing the proximal fragment, while the distal fragment is hyperextended by the central slip acting on the base of the middle phalanx.4 The most common complication after these fractures is malunion resulting in proximal interphalangeal joint (PIPJ) extensor lag, which is
Correspondence to: Dr. Michael Held, Groote Schuur Hospital, H49 Old Main Building, Observatory 7925, RSA, South Africa. Tel: (0027) 2140-66157, Fax: (0027) 2147-2709, E-mail: [email protected] 229
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concerns with the insertion of wires are tethering of soft tissues (especially the extensor tendon) and pin tract infection.3 Tendon adherence at the plate surface and surgical stiffness proportionate to the surgical dissection space are the most notorious drawbacks of open surgical techniques.3 Thus, a theoretically more rigid operative fixation may not end up with a better functional result.7 Many authors feel that minimally displaced and undisplaced fractures as well as fractures, which are stable post reduction, should be managed conservatively.6,8,9 This is the best way to achieve fracture union and preserve finger function.6,8 With conservative management, the metacarpophalangeal (MCP) joint is splinted in 90 flexion and the interphalangeal (IP) joints in full extension allowing active flexion at the PIP joint.6 MCP joint flexion shifts the extensor tendon distally so that two thirds of the phalanx are embraced by the extensor mechanism and the fracture is thus stabilised.4,6 Flexion at the MCP joint also serves to reduce the displacing force of the interossei as mentioned above. Flexion at the PIP joint compresses and further stabilises the fracture.6,8 The majority of our patient population are either unemployed or manual labourers. The employed patients are often casual labourers without income protection. Early return to work with a reasonable functional result is of paramount importance to them as they are often the only breadwinners in the family. Furthermore, theatre time and bed space is very limited in our setting, which makes conservative management an attractive option. In this prospective cohort study we aimed to assess the feasibility of conservatively managed extra-articular proximal phalanx fractures regarding functional and anatomical outcome.
Fig. 1 Local Algorithm. Displacement of the fracture is assessed radiologically. Reduction is attempted and maintained with a dorsal slab. Flexion of at least 90 at the MCP joint is paramount. The affected finger is buddy-taped to the adjacent finger to control rotation. If the reduction is found to be acceptable, the patients are followed up weekly with radiologic and clinical examinations. After three weeks, the slab is removed and union is assessed. The patients then continue with active range of motion exercises at the PIPJ and are seen again at six weeks to assess range of motion and joint stiffness. If reduction is not acceptable at any point, the patient is offered surgical stabilisation. In undisplaced fractures, the finger is buddy-strapped to the adjacent finger and the patient is followed up weekly.
articular involvement and fractures with bone loss were excluded. An attempt to reduce the fracture was made under local anaesthetic and the reduction was maintained with a dorsal slab, ensuring vigorously that flexion of at least 90 degrees at the metacarpophalangeal joint was maintained (Fig. 2). The affected finger was buddy-taped to the adjacent finger to control rotation. The palm was cleared to allow full active range of
METHODS This study included 23 patients (18 males, five females) with a mean age of 36 (range: 1860). All patients were treated according to our local algorithm (Fig. 1) for proximal phalangeal fractures. Data was collected prospectively. The mechanism of injury, fracture pattern and exact location of the fracture were documented. At a mean of seven weeks (range: 345) patients were assessed regarding union, malunion such as angular deformity and shortening, range of motion and stiffness. On presentation, the fracture was confirmed radiologically. Open fractures, multiple fractures, paediatric patients,
Fig. 2 Image of lateral radiograph of a proximal phalangeal fracture in reduced position. The position in the plaster slab of at least 90 of MCP joint flexion (white arrow on base of proximal phalanx) is crucial to oppose the pull of the interossei muscles. Right image: AP radiograph.
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Conservative Treatment of Fractures of the Proximal Phalanx
motion exercises. AP and lateral radiographs were taken to confirm the reduction. If the reduction was found to be acceptable, the patients were followed up weekly with radiographic and clinical examinations. No rotational deformity was accepted; 15 degrees of angular deformity in any plane and 3 mm of shortening were accepted. After three weeks, the slab was removed and union assessed clinically and radiologically. The patients then continued with active range of motion exercises at the PIPJ and were seen again at six weeks to assess range of motion and joint stiffness. Union was assessed radiologically and clinically. In cases where radiological confirmation of union could not be made with certainty, clinical signs such as pain-free active range of motion and no movement or pain at the fracture site were used to establish union. Surgical treatment was offered to patients in whom reduction could not be achieved initially or in whom failure of the conservative treatment was noted at follow-up. Stable, undisplaced fractures were managed with buddy strapping to the adjacent finger. Three patients were lost to follow-up at week three into their conservative fracture management. All of these patients were prisoners, and the prison health care worker assessed the fracture to be healed in an acceptable position and reported patients had returned to their daily activities. Comparison of proportions was assessed using Fisher’s exact test (two-sided), p < 0:05 was regarded as statistically significant.
RESULTS Patients were mostly young (mean age 36 years, range: 1860) and male (n ¼ 18, 78%). Eleven patients (47.8%) were unemployed. All other patients, except one (scholar), were general workers. The average delay to presentation was 4.6 days (range: 021). Most injuries were caused by blunt assaults (n ¼ 12, 52%) or in defence to such assaults. Falls (n ¼ 5, 22%) and crush injuries (n ¼ 3, 13%) were the reason for the injury in a smaller number of patients. Two patients were intoxicated at the time of the injury and could not recall how they injured their finger. Most fractures involved the proximal third of the proximal phalanx (n ¼ 12, 52%) and the middle third (n ¼ 10, 43%). Only one patient presented with a distal third proximal phalanx fracture. The middle finger was the most commonly affected (n ¼ 9, 40%), followed by index finger, ring finger (each: n ¼ 5, 22%) and little finger (n ¼ 4, 17%). Fourteen patients (61%) had fractures considered to be unstable, with nine
Fig. 3
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AP radiographs of complex fractures treated conservatively.
oblique fractures (40%) and five complex fractures (22%) respectively (Fig. 3). The remaining nine patients (40%) had simple transverse fractures. After reduction, 91% of the fractures (21 of 23) maintained an acceptable position in the dorsal slab (Fig. 4). The mean coronal angulation was four degrees (range: 045) with all but one case (45 ) measuring an angulation of less than 15 . The mean sagittal angulation was measured at two degrees (range: 08). There were two unacceptable positions identified. In one case an apex-volar angulation of 45 in the coronal plane was noted at two weeks after initial acceptable reduction (Fig. 5). Another patient presented at two weeks after reduction with a rotational deformity of 20 . Both patients underwent open reduction and internal fixation with a mini-fragment plate. Radiographic and clinical assessment of the 21 patients who completed the conservative regimen was performed at a mean of seven weeks (range: 345). All patients went on to union.
Fig. 4 Left image: AP Radiograph of a short oblique phalanx fracture. Middle and right image: reduction at three-week follow-up.
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Fig. 5 Lateral radiograph showing an apex-volar angulation of 45 (white arrow) at two weeks after initial acceptable reduction. The black line indicates a poorly applied plaster slab of less than 90 MCP joint flexion.
No MCP joint stiffness was documented. In two cases mild stiffness of the PIP joint was evident with a deficit to full extension of 20 degrees. Five of 14 patients (35.7%) with complex fracture patterns considered to be unstable had an initial extensor lag of 1525 degrees. In the group of nine patients with stable fracture patterns, this was observed in five patients (55.6%). The extensor lag resolved in all patients on follow-up providing MP joints remained supple. An average shortening of 1.1 mm (range: 03) was measured. Four patients had three millimetres of shortening, seven had two millimetres of shortening and the remaining patients had no shortening. In ten (90.9%) of these 11 patients with shortening an extensor lag of 1020 degrees was documented. None of the remaining patients had an extensor lag.
DISCUSSION In 2005, Kar et al.6 reported on conservatively treated proximal phalanx fractures with acceptable result in 85% of their cases with only 5% malunions. They judged their results according to the modified Buck-Gramko’s point assessment system and deemed excellent and good results as acceptable. These findings are comparable to our results of 91% acceptable outcome. Even though Kar et al. included unstable fractures, no mention is made of the number of unstable fractures and they experienced difficulties with long spiral, long oblique, and complex fractures. The most common mechanism of injury was road traffic accidents, which differs from our study where more than half of the fractures were caused by assaults. Most of their patients returned to work before six weeks.
Rajesh et al. in 20054 managed 24 fractures with a similar technique to ours and had only two unfavourable results according to the Belsky classification. Both patients had minimal pain at extreme range of motion. In total the authors showed 72% excellent results and 22% good results over a mean follow-up of 15 months. Ahmad et al. in 20062 compared the surgical management of spiral, oblique and displaced fractures to conservative management of undisplaced fractures. Among the 15 fractures managed conservatively there was only one malunion and one case of stiffness with decreased range of motion. There was no difference in results between the patients managed surgically and those managed conservatively. Singh et al. in 201110 compared conservative management to surgical management and noted 89% good results in the conservative group and 92% good results in the surgical group and concluded that unstable fractures should be managed surgically. In 2012 Franz et al.11 compared two different techniques of conservative management. One group was assigned to the use of the \LuCa" for immobilisation and the other group used a functional forearm cast. The \LuCa" or Lucerne Cast starts distal to the wrist crease and allows free movement of the wrist. Even though they managed spiral, oblique and longitudinal fractures, the majority of the fractures were transverse fractures. They reported a \high satisfaction rate". Osteosynthesis does not guarantee stability4 and as mentioned earlier, surgical management, including both Kirschner wires and plating, has multiple complications, most importantly surgical stiffness and soft tissue interference. Conservative management has fewer complications and allows bone healing and rehabilitation to occur simultaneously. 4;5 It avoids the complications of surgery and anaesthesia and has a smaller economic impact, both to the hospital and the patient who can often return to work sooner. In our setting most of the employed patients are manual labourers who rely heavily on their hands for income. Therefore a management strategy, which ensures an early and functional return to work without placing a larger burden on bed occupancy and theatre time will be of great value. The functional outcome therefore takes priority over anatomic reduction on radiographs. Conservative management is generally reserved for undisplaced or minimally displaced fractures, which are stable post reduction.1,8,9,12,13 With splinting and early range of motion
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Conservative Treatment of Fractures of the Proximal Phalanx
exercises, the patients will in general have an acceptable outcome with fewer complications.36,10 Most authors recommend that unstable fractures such as spiral, oblique and complex fractures should be managed surgically.2,9,10,12 Sixty-one percent of the fractures treated in this study were considered unstable, such as oblique and complex fractures (Fig. 3), yet, contrary to current recommendations, were managed conservatively. All patients in our group had dorsal splinting. The most important advantage of dorsal compared to volar slabs is that the IP joints remain free for range of motion exercises. We also feel that flexion of the MP joints of more than 90 degrees can be maintained more predictably than with volar slabs. Our guidelines for an acceptable deformity are similar to other studies, especially regarding, rotation and angulation. The accepted angulation in all planes was deemed acceptable if it was less than 15 , similar to other studies where on AP radiograph 15 ,4,5 20 10 and 25 11 and on lateral radiograph 10 4,5,11 and 15 10 of angulation was accepted. As most other authors we accepted no rotation.4,10,11 In our study, shortening of up to 3 mm was accepted where most previous studies accepted no shortening,4,10,11 although one study accepted 4 mm of shortening.5 In our study an average shortening of 1.1 mm (range: 03) was measured after union. Four patients had 3 mm of shortening, seven had 2 mm of shortening and the remaining 12 patients had no shortening. 10 to 15 of extensor lag must be expected for each millimetre of shortening.3 In our cohort, an associated extensor lag of 1525 was found in ten of the 11 fractures (90.9%) with shortening. None of these patients had a remaining lag with functional deficit at their final follow-up. This might be due to intrinsic resetting of the extensor mechanism with continued physiotherapy after the removal of the dorsal slab. No significant difference was found in the occurrence of extensor lag in stable fractures (five of nine patients, 55%) compared to unstable fracture patterns (five of 14 patients, 35.7%; p value: 0.42). The duration of immobilisation of three weeks in our study is similar to previous studies, as most authors agree that immobilisation for longer than three to four weeks leads to worse results.2,46,11,14,15 The results in our study are also comparable to other studies.4,10,11 Twenty-one of 23 patients (91%) had an acceptable position on radiographs after treatment (Fig. 4). The two patients falling outside this group included a patient with a 45 angular apex volar deformity, which was noted at two-week follow up (Fig. 3). On the follow-up radiographs, it is evident
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that the dorsal slab was poorly applied as it did not effect MCP joint flexion of at least 90 . In another finger, with a short oblique mid-shaft fracture of the proximal phalanx, rotational deformity of at least 20 was evident and we noted that the buddy strapping to the adjacent fingers was inadequate as it was loose. Both these patients had an open reduction and internal fixation through a lateral approach with a minifragment plate performed at two weeks. Both patients went on to union with full range of motion and return to work within six weeks of operative treatment. None of the remaining 21 patients had MCP joint stiffness at the six-week follow up, yet, two patients had PIP joint stiffness with a deficit to full extension of 20 . In both cases the patients were unable to exercise the PIP joint as the padding was too bulky over the volar aspect of the hand. Both of these patients returned to work and the extensor lag did not affect their activities of daily living. All 21 of the fractures, which were managed conservatively, united. The limitation of this study is a relatively short follow-up, yet all patients completed treatment and were discharged from our unit after their return to work and activities of daily living had been ensured.
CONCLUSION Most extra-articular fractures of the proximal phalanx can be treated conservatively with acceptable results. This includes complex and oblique fractures, which would have conventionally been managed operatively. Flexion splinting at the MCP joint can serve to convert these inherently unstable fractures into relatively stable fractures. It is important to follow these cases up weekly, both radiologically and clinically to screen for loss of reduction and intervene appropriately. During this time physiotherapy is paramount to avoid stiffness of the affected joints.
References 1. Drenth DJ, Klasen HJ, External fixation for phalangeal and metacarpal fractures, J Bone Joint Surg Br 80-B(2):227230, 1998. 2. Ahmad M, Hussain SS, Rafiq Z, Tariq F, Khan MI, Malik SA, Management of phalangeal fractures of hand, J Ayub Med Coll Abbottabad 18(4):3841, 2006. 3. Henry MH, Fractures of the proximal phalanx and metacarpals of the hand: preferred methods of stabilization, J Am Acad Orthop Surg 16:586595, 2008.
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4. Rajesh G, Ip WY, Chow SP, Fung BKK, Dynamic treatment of proximal phalanx fracture of the hand, J Orthop Surg 15(2):211215, 2007. 5. Freeland AE, Hardy MA, Singletary S, Rehabilitation for proximal phalangeal fractures, J Hand Ther 16:129142, 2003. 6. Kar A, Patni P, Dayama RL, Meena DS, Treatment of closed unstable extra articular proximal phalangeal fractures of the hand by closed reduction and dorsal extension block cast, Indian J Ortop 39:158162, 2005. 7. Lu WW, Furumachi K, Ip WY, Chow SP, Fixation of comminuted phalangeal fractures, J Hand Surgery Br 21B(6):765767, 1996. 8. Della Santa D, Treatment of fractures of fingers. What’s new? J Hand Surg Br 28(2):24, 2003. 9. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, Green’s Operative Hand Surgery, 5th ed., Churchill Livingstone, Philadelphia, 2005. 10. Özçelik D, Toplu G, Ünveren T, Kaçağan F, Şenyuva CTG, Long-term objective results of proximal phalanx fracture treatment, Turk J Trauma Emerg Surg 17(3):253260, 2011.
11. Hornbach EE, Cohen MS, Closed reduction and percutaneous pinning of fractures of the proximal phalanx, J Hand Surg Br 26B(1):4549, 2001. 12. Stanton JS, Dias JJ, Burke FD, Fractures of the tubular bones of the hand, J Hand Surg 32E(6):626636, 2007. 13. Al-Qattan MM, Closed reduction and percutaneous K-wire versus open reduction and interosseous loop wires for displaced unstable fractures of the shaft of the proximal phalanx of the fingers in industrial workers, J Hand Surg Eur 33E(5):552556, 2008. 14. Singh J, Jain K, Mruthyunjaya, Ravishankar R, Outcome of closed proximal phalangeal fractures of the hand, Indian J Orthop 45(5):432438, 2011. 15. Franz T, Von Wartburg U, Schibli-Beer S, Jung FJ, Jandali AR, Calcagni M, Hug U, Extra articular fractures of the proximal phalanges of the fingers: a comparison of 2 methods of functional, conservative treatment, J Hand Surg 37A:889898, 2012.
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Hand Surgery, Vol. 18, No. 2 (2013) 229234 © World Scientific Publishing Company DOI: 10.1142/S0218810413500287
CONSERVATIVE TREATMENT OF FRACTURES OF THE PROXIMAL PHALANX: AN OPTION EVEN FOR UNSTABLE FRACTURE PATTERNS
Hand Surg. 2013.18:229-234. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/22/15. For personal use only.
Michael Held, Pieter Jordaan, Maritz Laubscher, Martin Singer and Michael Solomons Martin Singer Hand Unit, Orthopaedic Department Groote Schuur Hospital, University of Cape Town, South Africa Received 7 December 2012; Revised 17 February 2013; Accepted 18 February 2013 ABSTRACT Purpose: The purpose of the study was to assess the efficacy of the conservative management of proximal phalangeal fractures in a dorsal plaster slab. Methods: Twenty-three consecutive patients with extra-articular proximal phalangeal fractures were included in this prospective study. Fourteen patients (62%) presented with fractures considered unstable. The fractures were reduced and the position was held with a dorsal plaster slab for three weeks. The patients were followed up for an average of seven weeks (range 2 to 45) after the injury. Range of motion of the finger and radiological evidence of union, non-union or malunion was documented after removal of the plaster. Results: Ninety-one percent of fractures maintained an acceptable reduction. All cases measured less than 15 of angulation. On average 1,1 mm of shortening was measured. In two (9%) cases the reduction was not accepted on follow up assessment and the fractures were managed surgically. Conclusion: Most extra-articular proximal phalanx fractures can be managed conservatively with acceptable results. Keywords: Proximal Phalanx; Complex Finger Fractures; Conservative Management; Unstable Finger Fractures.
INTRODUCTION
worsened by extensor tendon zone IV adherence and shortening at the fracture site.3,5,6 One millimetre of shortening leads to 12 of extensor lag at the PIPJ.3 Multiple treatment protocols and options, ranging from splinting, percutaneous wires, external fixators, interfragmentary screw fixation to mini fragment plates point towards the challenges arising with the management of fractures of the proximal phalanx. The key to acceptable functional results is to achieve a stable reduction with correct alignment and to allow early mobilisation of the digit. The general
Phalangeal fractures are almost twice as common as metacarpal fractures and most occur in the proximal phalanx.13 Fractures usually present with apex volar angulation due to the insertion of the interosseus muscle onto the base of the proximal phalanx, thus flexing the proximal fragment, while the distal fragment is hyperextended by the central slip acting on the base of the middle phalanx.4 The most common complication after these fractures is malunion resulting in proximal interphalangeal joint (PIPJ) extensor lag, which is
Correspondence to: Dr. Michael Held, Groote Schuur Hospital, H49 Old Main Building, Observatory 7925, RSA, South Africa. Tel: (0027) 2140-66157, Fax: (0027) 2147-2709, E-mail: [email protected] 229
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concerns with the insertion of wires are tethering of soft tissues (especially the extensor tendon) and pin tract infection.3 Tendon adherence at the plate surface and surgical stiffness proportionate to the surgical dissection space are the most notorious drawbacks of open surgical techniques.3 Thus, a theoretically more rigid operative fixation may not end up with a better functional result.7 Many authors feel that minimally displaced and undisplaced fractures as well as fractures, which are stable post reduction, should be managed conservatively.6,8,9 This is the best way to achieve fracture union and preserve finger function.6,8 With conservative management, the metacarpophalangeal (MCP) joint is splinted in 90 flexion and the interphalangeal (IP) joints in full extension allowing active flexion at the PIP joint.6 MCP joint flexion shifts the extensor tendon distally so that two thirds of the phalanx are embraced by the extensor mechanism and the fracture is thus stabilised.4,6 Flexion at the MCP joint also serves to reduce the displacing force of the interossei as mentioned above. Flexion at the PIP joint compresses and further stabilises the fracture.6,8 The majority of our patient population are either unemployed or manual labourers. The employed patients are often casual labourers without income protection. Early return to work with a reasonable functional result is of paramount importance to them as they are often the only breadwinners in the family. Furthermore, theatre time and bed space is very limited in our setting, which makes conservative management an attractive option. In this prospective cohort study we aimed to assess the feasibility of conservatively managed extra-articular proximal phalanx fractures regarding functional and anatomical outcome.
Fig. 1 Local Algorithm. Displacement of the fracture is assessed radiologically. Reduction is attempted and maintained with a dorsal slab. Flexion of at least 90 at the MCP joint is paramount. The affected finger is buddy-taped to the adjacent finger to control rotation. If the reduction is found to be acceptable, the patients are followed up weekly with radiologic and clinical examinations. After three weeks, the slab is removed and union is assessed. The patients then continue with active range of motion exercises at the PIPJ and are seen again at six weeks to assess range of motion and joint stiffness. If reduction is not acceptable at any point, the patient is offered surgical stabilisation. In undisplaced fractures, the finger is buddy-strapped to the adjacent finger and the patient is followed up weekly.
articular involvement and fractures with bone loss were excluded. An attempt to reduce the fracture was made under local anaesthetic and the reduction was maintained with a dorsal slab, ensuring vigorously that flexion of at least 90 degrees at the metacarpophalangeal joint was maintained (Fig. 2). The affected finger was buddy-taped to the adjacent finger to control rotation. The palm was cleared to allow full active range of
METHODS This study included 23 patients (18 males, five females) with a mean age of 36 (range: 1860). All patients were treated according to our local algorithm (Fig. 1) for proximal phalangeal fractures. Data was collected prospectively. The mechanism of injury, fracture pattern and exact location of the fracture were documented. At a mean of seven weeks (range: 345) patients were assessed regarding union, malunion such as angular deformity and shortening, range of motion and stiffness. On presentation, the fracture was confirmed radiologically. Open fractures, multiple fractures, paediatric patients,
Fig. 2 Image of lateral radiograph of a proximal phalangeal fracture in reduced position. The position in the plaster slab of at least 90 of MCP joint flexion (white arrow on base of proximal phalanx) is crucial to oppose the pull of the interossei muscles. Right image: AP radiograph.
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Conservative Treatment of Fractures of the Proximal Phalanx
motion exercises. AP and lateral radiographs were taken to confirm the reduction. If the reduction was found to be acceptable, the patients were followed up weekly with radiographic and clinical examinations. No rotational deformity was accepted; 15 degrees of angular deformity in any plane and 3 mm of shortening were accepted. After three weeks, the slab was removed and union assessed clinically and radiologically. The patients then continued with active range of motion exercises at the PIPJ and were seen again at six weeks to assess range of motion and joint stiffness. Union was assessed radiologically and clinically. In cases where radiological confirmation of union could not be made with certainty, clinical signs such as pain-free active range of motion and no movement or pain at the fracture site were used to establish union. Surgical treatment was offered to patients in whom reduction could not be achieved initially or in whom failure of the conservative treatment was noted at follow-up. Stable, undisplaced fractures were managed with buddy strapping to the adjacent finger. Three patients were lost to follow-up at week three into their conservative fracture management. All of these patients were prisoners, and the prison health care worker assessed the fracture to be healed in an acceptable position and reported patients had returned to their daily activities. Comparison of proportions was assessed using Fisher’s exact test (two-sided), p < 0:05 was regarded as statistically significant.
RESULTS Patients were mostly young (mean age 36 years, range: 1860) and male (n ¼ 18, 78%). Eleven patients (47.8%) were unemployed. All other patients, except one (scholar), were general workers. The average delay to presentation was 4.6 days (range: 021). Most injuries were caused by blunt assaults (n ¼ 12, 52%) or in defence to such assaults. Falls (n ¼ 5, 22%) and crush injuries (n ¼ 3, 13%) were the reason for the injury in a smaller number of patients. Two patients were intoxicated at the time of the injury and could not recall how they injured their finger. Most fractures involved the proximal third of the proximal phalanx (n ¼ 12, 52%) and the middle third (n ¼ 10, 43%). Only one patient presented with a distal third proximal phalanx fracture. The middle finger was the most commonly affected (n ¼ 9, 40%), followed by index finger, ring finger (each: n ¼ 5, 22%) and little finger (n ¼ 4, 17%). Fourteen patients (61%) had fractures considered to be unstable, with nine
Fig. 3
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AP radiographs of complex fractures treated conservatively.
oblique fractures (40%) and five complex fractures (22%) respectively (Fig. 3). The remaining nine patients (40%) had simple transverse fractures. After reduction, 91% of the fractures (21 of 23) maintained an acceptable position in the dorsal slab (Fig. 4). The mean coronal angulation was four degrees (range: 045) with all but one case (45 ) measuring an angulation of less than 15 . The mean sagittal angulation was measured at two degrees (range: 08). There were two unacceptable positions identified. In one case an apex-volar angulation of 45 in the coronal plane was noted at two weeks after initial acceptable reduction (Fig. 5). Another patient presented at two weeks after reduction with a rotational deformity of 20 . Both patients underwent open reduction and internal fixation with a mini-fragment plate. Radiographic and clinical assessment of the 21 patients who completed the conservative regimen was performed at a mean of seven weeks (range: 345). All patients went on to union.
Fig. 4 Left image: AP Radiograph of a short oblique phalanx fracture. Middle and right image: reduction at three-week follow-up.
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Fig. 5 Lateral radiograph showing an apex-volar angulation of 45 (white arrow) at two weeks after initial acceptable reduction. The black line indicates a poorly applied plaster slab of less than 90 MCP joint flexion.
No MCP joint stiffness was documented. In two cases mild stiffness of the PIP joint was evident with a deficit to full extension of 20 degrees. Five of 14 patients (35.7%) with complex fracture patterns considered to be unstable had an initial extensor lag of 1525 degrees. In the group of nine patients with stable fracture patterns, this was observed in five patients (55.6%). The extensor lag resolved in all patients on follow-up providing MP joints remained supple. An average shortening of 1.1 mm (range: 03) was measured. Four patients had three millimetres of shortening, seven had two millimetres of shortening and the remaining patients had no shortening. In ten (90.9%) of these 11 patients with shortening an extensor lag of 1020 degrees was documented. None of the remaining patients had an extensor lag.
DISCUSSION In 2005, Kar et al.6 reported on conservatively treated proximal phalanx fractures with acceptable result in 85% of their cases with only 5% malunions. They judged their results according to the modified Buck-Gramko’s point assessment system and deemed excellent and good results as acceptable. These findings are comparable to our results of 91% acceptable outcome. Even though Kar et al. included unstable fractures, no mention is made of the number of unstable fractures and they experienced difficulties with long spiral, long oblique, and complex fractures. The most common mechanism of injury was road traffic accidents, which differs from our study where more than half of the fractures were caused by assaults. Most of their patients returned to work before six weeks.
Rajesh et al. in 20054 managed 24 fractures with a similar technique to ours and had only two unfavourable results according to the Belsky classification. Both patients had minimal pain at extreme range of motion. In total the authors showed 72% excellent results and 22% good results over a mean follow-up of 15 months. Ahmad et al. in 20062 compared the surgical management of spiral, oblique and displaced fractures to conservative management of undisplaced fractures. Among the 15 fractures managed conservatively there was only one malunion and one case of stiffness with decreased range of motion. There was no difference in results between the patients managed surgically and those managed conservatively. Singh et al. in 201110 compared conservative management to surgical management and noted 89% good results in the conservative group and 92% good results in the surgical group and concluded that unstable fractures should be managed surgically. In 2012 Franz et al.11 compared two different techniques of conservative management. One group was assigned to the use of the \LuCa" for immobilisation and the other group used a functional forearm cast. The \LuCa" or Lucerne Cast starts distal to the wrist crease and allows free movement of the wrist. Even though they managed spiral, oblique and longitudinal fractures, the majority of the fractures were transverse fractures. They reported a \high satisfaction rate". Osteosynthesis does not guarantee stability4 and as mentioned earlier, surgical management, including both Kirschner wires and plating, has multiple complications, most importantly surgical stiffness and soft tissue interference. Conservative management has fewer complications and allows bone healing and rehabilitation to occur simultaneously. 4;5 It avoids the complications of surgery and anaesthesia and has a smaller economic impact, both to the hospital and the patient who can often return to work sooner. In our setting most of the employed patients are manual labourers who rely heavily on their hands for income. Therefore a management strategy, which ensures an early and functional return to work without placing a larger burden on bed occupancy and theatre time will be of great value. The functional outcome therefore takes priority over anatomic reduction on radiographs. Conservative management is generally reserved for undisplaced or minimally displaced fractures, which are stable post reduction.1,8,9,12,13 With splinting and early range of motion
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exercises, the patients will in general have an acceptable outcome with fewer complications.36,10 Most authors recommend that unstable fractures such as spiral, oblique and complex fractures should be managed surgically.2,9,10,12 Sixty-one percent of the fractures treated in this study were considered unstable, such as oblique and complex fractures (Fig. 3), yet, contrary to current recommendations, were managed conservatively. All patients in our group had dorsal splinting. The most important advantage of dorsal compared to volar slabs is that the IP joints remain free for range of motion exercises. We also feel that flexion of the MP joints of more than 90 degrees can be maintained more predictably than with volar slabs. Our guidelines for an acceptable deformity are similar to other studies, especially regarding, rotation and angulation. The accepted angulation in all planes was deemed acceptable if it was less than 15 , similar to other studies where on AP radiograph 15 ,4,5 20 10 and 25 11 and on lateral radiograph 10 4,5,11 and 15 10 of angulation was accepted. As most other authors we accepted no rotation.4,10,11 In our study, shortening of up to 3 mm was accepted where most previous studies accepted no shortening,4,10,11 although one study accepted 4 mm of shortening.5 In our study an average shortening of 1.1 mm (range: 03) was measured after union. Four patients had 3 mm of shortening, seven had 2 mm of shortening and the remaining 12 patients had no shortening. 10 to 15 of extensor lag must be expected for each millimetre of shortening.3 In our cohort, an associated extensor lag of 1525 was found in ten of the 11 fractures (90.9%) with shortening. None of these patients had a remaining lag with functional deficit at their final follow-up. This might be due to intrinsic resetting of the extensor mechanism with continued physiotherapy after the removal of the dorsal slab. No significant difference was found in the occurrence of extensor lag in stable fractures (five of nine patients, 55%) compared to unstable fracture patterns (five of 14 patients, 35.7%; p value: 0.42). The duration of immobilisation of three weeks in our study is similar to previous studies, as most authors agree that immobilisation for longer than three to four weeks leads to worse results.2,46,11,14,15 The results in our study are also comparable to other studies.4,10,11 Twenty-one of 23 patients (91%) had an acceptable position on radiographs after treatment (Fig. 4). The two patients falling outside this group included a patient with a 45 angular apex volar deformity, which was noted at two-week follow up (Fig. 3). On the follow-up radiographs, it is evident
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that the dorsal slab was poorly applied as it did not effect MCP joint flexion of at least 90 . In another finger, with a short oblique mid-shaft fracture of the proximal phalanx, rotational deformity of at least 20 was evident and we noted that the buddy strapping to the adjacent fingers was inadequate as it was loose. Both these patients had an open reduction and internal fixation through a lateral approach with a minifragment plate performed at two weeks. Both patients went on to union with full range of motion and return to work within six weeks of operative treatment. None of the remaining 21 patients had MCP joint stiffness at the six-week follow up, yet, two patients had PIP joint stiffness with a deficit to full extension of 20 . In both cases the patients were unable to exercise the PIP joint as the padding was too bulky over the volar aspect of the hand. Both of these patients returned to work and the extensor lag did not affect their activities of daily living. All 21 of the fractures, which were managed conservatively, united. The limitation of this study is a relatively short follow-up, yet all patients completed treatment and were discharged from our unit after their return to work and activities of daily living had been ensured.
CONCLUSION Most extra-articular fractures of the proximal phalanx can be treated conservatively with acceptable results. This includes complex and oblique fractures, which would have conventionally been managed operatively. Flexion splinting at the MCP joint can serve to convert these inherently unstable fractures into relatively stable fractures. It is important to follow these cases up weekly, both radiologically and clinically to screen for loss of reduction and intervene appropriately. During this time physiotherapy is paramount to avoid stiffness of the affected joints.
References 1. Drenth DJ, Klasen HJ, External fixation for phalangeal and metacarpal fractures, J Bone Joint Surg Br 80-B(2):227230, 1998. 2. Ahmad M, Hussain SS, Rafiq Z, Tariq F, Khan MI, Malik SA, Management of phalangeal fractures of hand, J Ayub Med Coll Abbottabad 18(4):3841, 2006. 3. Henry MH, Fractures of the proximal phalanx and metacarpals of the hand: preferred methods of stabilization, J Am Acad Orthop Surg 16:586595, 2008.
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4. Rajesh G, Ip WY, Chow SP, Fung BKK, Dynamic treatment of proximal phalanx fracture of the hand, J Orthop Surg 15(2):211215, 2007. 5. Freeland AE, Hardy MA, Singletary S, Rehabilitation for proximal phalangeal fractures, J Hand Ther 16:129142, 2003. 6. Kar A, Patni P, Dayama RL, Meena DS, Treatment of closed unstable extra articular proximal phalangeal fractures of the hand by closed reduction and dorsal extension block cast, Indian J Ortop 39:158162, 2005. 7. Lu WW, Furumachi K, Ip WY, Chow SP, Fixation of comminuted phalangeal fractures, J Hand Surgery Br 21B(6):765767, 1996. 8. Della Santa D, Treatment of fractures of fingers. What’s new? J Hand Surg Br 28(2):24, 2003. 9. Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, Green’s Operative Hand Surgery, 5th ed., Churchill Livingstone, Philadelphia, 2005. 10. Özçelik D, Toplu G, Ünveren T, Kaçağan F, Şenyuva CTG, Long-term objective results of proximal phalanx fracture treatment, Turk J Trauma Emerg Surg 17(3):253260, 2011.
11. Hornbach EE, Cohen MS, Closed reduction and percutaneous pinning of fractures of the proximal phalanx, J Hand Surg Br 26B(1):4549, 2001. 12. Stanton JS, Dias JJ, Burke FD, Fractures of the tubular bones of the hand, J Hand Surg 32E(6):626636, 2007. 13. Al-Qattan MM, Closed reduction and percutaneous K-wire versus open reduction and interosseous loop wires for displaced unstable fractures of the shaft of the proximal phalanx of the fingers in industrial workers, J Hand Surg Eur 33E(5):552556, 2008. 14. Singh J, Jain K, Mruthyunjaya, Ravishankar R, Outcome of closed proximal phalangeal fractures of the hand, Indian J Orthop 45(5):432438, 2011. 15. Franz T, Von Wartburg U, Schibli-Beer S, Jung FJ, Jandali AR, Calcagni M, Hug U, Extra articular fractures of the proximal phalanges of the fingers: a comparison of 2 methods of functional, conservative treatment, J Hand Surg 37A:889898, 2012.
