Distal phalanx fracture

Distal phalanx fracture

1. Distal phalanx fracture Naranjargalan ,.MD November 2, 2015 20 th presentation

2. Fractures of the Distal Phalanx The distal phalanx is common fracture in the hand. (15-19% of hand fracture in adults) E specially injuries involving the thumb, index and middle fingers.

3. Fractures of the Distal Phalanx Anatomy Extensor and flexor tendons insert into the base of the distal phalanx

4. Fractures of the Distal Phalanx Mechanism of Injury Crush injury Sport-related injury Sudden extension against a flexed finger (rugger jersey) Sudden flexion against an extended finger (baseball hitting end of extended finger)

5. Fractures of the Distal Phalanx Classification Shaft fracture Transverse fracture Longitudinal Tuft fracture (associated with nail bed fracture and open fracture) Dorsal Base (Mallet finger) Volar base ( Type III Jersey finger) Salter-Harris

6. Salter-Harris

7. Fractures of the Distal Phalanx Associated Injuries Nailbed lacerations Nail plate avulsion Skin lacerations Subungal hematoma Physical Exam Check both flexor and extensor function S ensory exam

8. Fractures of the Distal Phalanx Treatment Non-displaced or minimally displaced can use variety of splints. /transverse fracture/ Tight circumferential taping should not be used because of an increased risk of circulatory compromise. Splinting is generally maintained for about 2-3 weeks . If necessary provided use until 6 weeks.

9. Fractures of the Distal Phalanx Treatment Open fractures with nailbed laceration stitches using 8.0 absorbable suture material should be used . Be careful to suture the edges of the nail bed

10. Fractures of the Distal Phalanx Treatment DIP Dislocation AP, lateral + oblique view of affected finger. Mallet finger

11. Fractures of the Distal Phalanx Treatment Mallet Finger Classification 1. Closed No fracture ( full extension or hyperextension in the DIP joint ) Maintain for 8weeks, followed by nightime splint use for 2-3 weeks.

12. Fractures of the Distal Phalanx Treatment Mallet Finger Classification 2. Open = lacerations repaired with running suture

13. Fractures of the Distal Phalanx Treatment Mallet Finger Classification 3. Closed with fracture closed reduction with  Extension Block Pinning = K-wire 6 Weeks: Remove k-wire, wean from splint use 3 Months: Resume full activities. Assess ROM.

14. K-wire

15. Incisions Dorsal to the DIP joint incision Dorsal to IP joint of the thumb incision

16. Fractures of the Distal Phalanx Jersey finger (Flexor Tendon Avulsion) Anatomy Flexor digitorum profundus tendon inserts into the base of the distal phalanx

17. Fractures of the Distal Phalanx Mechanism of Injury Hyperextension against a flexed DIP joint None associated injuries Ring finger most commonly involved

18. Fractures of the Distal Phalanx Treatment Jersey Finger Classification Type I- vincula ruptured with tendon retracted to the palm Primary repair within 10 days A ble to fully flex PIP joint

19. Fractures of the Distal Phalanx Treatment Jersey Finger Classification Type II- vincula intact with tendon retracted to level of the PIP joint. Primary repair as soon as possible. Primary repair may still be possible several weeks U nable to flex PIP joint

20. Fractures of the Distal Phalanx Treatment Jersey Finger Classification Type III- Fracture fragment retains tendon at DIP joint Repair of fracture fragment (6 weeks)

21. Fractures of the Distal Phalanx Treatment Jersey Finger Classification Type IV- Fracture fragment has tendon avulsed off and retracted Repair of fracture fragment and tendon repair (12 weeks)

22. Fractures of the Distal Phalanx Treatment T ourniquet high on arm, pre-operative antibiotic Volar zigzag incision from just proximal to PIP joint to just distal to DIP joint Expose flexor tendon sheath Transverse incision just distal to A2 pulley, look for tendon If unable to locate tendon, make small transverse incision just proximal to A1 (1cm) pulley(at the level of the distal palmar crease). Incise sheath proximal to A1 pulley, pull tendon end into wound Place 3-0 Prolene stitch in tendon end

23. Fractures of the Distal Phalanx Treatment Pass small catheter/suture passer from PIP joint incision into palm through the flexor tendon sheath. Pull tendon into finger past A2 pulley (1.5-1.7cm) Pass tendon under A4 pulley (0.5-0.7cm) to its distal phalanx insertion Prepare bone bed on distal phalanx. Be sure to preserve palmar plate. Drill K-wire into distal phalangeal bone bed exiting through the mid portion of the nail plate. Tie suture over a button on the top of the nail plate. (alternative =suture anchor instead of bone tunnels and button) Irrigate and then Close wounds Dorsal splint with wrist in slight flexion

24. Jersey Finger Follow-up Care Splint for 4-6 weeks Begin passive flexion exercises at one week Remove suture/button at 4 weeks and begin protected active motion Continue activity limitations for 12 weeks.

25. Complications Malunion : Malrotation requiring rotational osteotomy Tendon adherence: Common, especially in crush injuries Nonunion : Rare, but more common with open than with closed fractures Soft-tissue interposition Infections Stiffness: Immobilization for >3 weeks can result in permanent loss of motion.

26. Paronychia Clean area with alcohol or betadine Perform digital nerve block Area of greatest fluctuance Remove pus Debride nail if necessary Antibiotics Dressing

27. Paronychia

28. Felon Abscess of distal pulp Results from penetrating trauma Bacteria trough eccine sweat glands Pulp is tense and tender Significant edema

29. Felon Fish-mouth incision Hockey-stick/ J-incision Transverse palmar incision

30. Thank you for your attention 

31. Failed treatment