Proximal Phalanx Fractures physical therapy.pptx

Proximal Phalanx Fractures physical therapy rehabilitation

1. Proximal Phalanx Fractures

2. anatomy

3. Central slip

4. signs and symptoms : Significant Pain and Tenderness: Sharp, localized pain that worsens with movement or pressure . Swelling and Bruising: The injured finger may appear noticeably larger and discolored Deformity and Malrotation : The finger might look visibly crooked or twisted. A rotational deformity can be a major issue, often identified by the "scissoring" of fingers when trying to make a fist . Limited Range of Motion: Difficulty and pain when trying to bend or straighten the finger . Crepitus : A grinding or crackling sensation indicating bone fragments rubbing together .

5. Diagnosis involves :   Clinical Examination : History of the injury check for signs like deformity and swelling. Clinical examination : assess for malrotation by asking you to make a fist . * Imaging (X-rays): X-rays from multiple angles are the standard for confirming the fracture's location, type, and severity .

6. Sites of Proximal Phalanx Fractures : Base Fractures: Occur at the end of the bone near the palm . Shaft Fractures: Breaks in the middle of the bone, which can be straight across (transverse), angled (oblique), or twisting (spiral) . Condylar Fractures: Breaks at the end of the bone closest to the fingertip, often involving the joint

7. treatment Fractures and dislocations involving the hand are classified as Appropriate treatment is determined ac cording to the stability of fracture. Stable fractures are those that would not displace if some degree of early digital motion were allowed. splinting Unstable fractures are those that displace to an unacceptable degree if early digital motion is allowed. most unstable fractures should undergo closed reduction and percutaneous pinning or open reduction internal fixation (ORIF) to allow early protected digital motion and thus prevent stiffness .

8. Greer’s principles of splinting * Greer’s principles of splinting (REDUCE) should be incorporated in casting or splinting of these fractures . R: Reduction of the fracture is maintained . E: Eliminate contractures through proper positioning . D: Don’t immobilize any of these fractures for more than 3 weeks . U: Uninvolved joint should not be splinted in stable fractures . C: Creases of the skin should not be obstructed by the splint .

9. RICE (rest, ice, compression , elevation ) is emphasized for edema control. Edema is poorly tolerated by the hand. Distended , edematous joints predictably move into positions that permit the greatest expansion of the joint capsule and collateral ligaments. Edema postures the hand into wrist flexion , metacarpophalangeal joint extension, interphalangeal joint flexion, and thumb adduction: a “dropped claw hand.” Functional splinting seeks to place the hand in a position that avoids this deformed posturing . All splinting programs for metacarpal or phalangeal fractures recognize the need to position the metacarpophalangeal joints in flexion to avoid extension contractures . * The interphalangeal joints typically are rested in full extension .  

10. E : Early active tendon gliding is encouraged. * The most important tendon gliding exercises (Fig. 4.1) to initiate early rehab are for the flexor digitorum superficialis (FDS), FDP, extensor digitorum communis (EDC), and central slip to prevent tendon adherence to fracture callus .

11. General Principles of rehabilitation early active ROM and tendon gliding using synergistic wrist positions and blocking techniques, including blocking splints . * Radiographic healing (shows the original fracture line) takes longer time than clinical healing (absence of point tenderness). At 6 weeks , with a nontender clinically healed fracture the radiograph typically still shows the original fracture line. The clinician must go by clinical examination (presence or absence of point tenderness) when making treatment decisions .

12. Surgical indications Fractures that often require surgical intervention include the following : Open fractures Comminuted displaced fractures Fractures associated with joint dislocation or subluxation Displaced or angulated or malrotated spiral fractures Displaced intra-articular fractures, especially around the PIP joint

13. Fractures in which there is loss of bone Multiple fractures Because of the hand’s tends to quickly form a permanently stiffening scar , unstable fractures must be surgically converted to stable fractures (e.g., pinning) to allow early ROM exercises. Failure to use early ROM will result in a stiff hand with poor function regardless of radiographic bony healing . Accompanied injuries

14. The Role of Physical Therapy and Rehabilitation These injuries are particularly challenging due to the high risk of complications like stiffness and malrotation , which can significantly impact hand function Rehabilitation is a critical part of the recovery process , aiming to restore full hand function while preventing complications . The process is typically divided into three phases .

15. Phase 1: Immobilization and Early Protected Motion (3 -6 weeks) * Goal: Allow the fracture to heal . * Method: The finger is immobilized in a splint or cast, often in a specific "safe position" to prevent joint stiffness . Elevation of the hand to manage swelling * Activities: Gentle movement of unaffected fingers, wrist, and thumb . .

16. Phase 2: Regaining Range of Motion (Post-Immobilization ) (3 -6 weeks) Goal : Restore joint mobility . Method : Once the fracture is stable , the focus shifts to exercises . Activities : Active Range of Motion ( AROM ): Exercises like making different types of fists ("full," "hook," "straight") to regain full movement . Passive Range of Motion ( PROM ) to stretch stiff joints . Splinting : Night splints may be used to maintain progress .

17. Phase 3: Strengthening and Functional Activities (6+ weeks) * Goal: Regain strength and dexterity to return to normal activities . * Method: Progressive strengthening exercises . * Activities : * Strengthening: Squeezing a soft ball or putty for grip strength; pinch exercises for fine motor control . * Functional Tasks: Incorporating activities like writing , typing , and using tools back into your routine .

18. complications stiffness * Phalangeal fractures respond less favorably to immobilization than metacarpal fractures, with a predicted 84% return of motion compared with 96% return of motion in the metacarpals ( Shehadi 1991) . If phalangeal immobilization is continued for longer than 4 weeks , the motion drops to 66% . Reasons cited for poor results in the literature typically are comminuted fractures, open fractures, and multiple fractures .

19. Weiss and Hastings (1993) investigated initiation of motion in patients with proximal phalangeal fractures treated with Kirschner -wire fixation and found no long-term differences in finger range of motion when motion was initiated between 1 and 21 days; however, if motion was delayed more than 21 days , there was a significant loss of motion . * Comminuted phalangeal fractures, especially those that involve diaphyseal segments with thick cortices, may be slow to heal and may require fixation for up to 6 weeks

20. malunion * Phalangeal fractures lack intrinsic muscle support, are more unstable than metacarpal fractures, and are adversely affected by the tension in the long tendons of the fingers . * Because of the pull of the FDS insertion into the middle phalanx, a proximal fracture of the (middle phalanx) will angulate with the fracture apex dorsal and a distal fracture will involve angulation with the apex volar (Fig. 5.3). Because of the deforming tendon forces, fractures in these areas that present initially as displaced are unlikely to remain reduced after reduction and typically require operative fixation .

21. Malrotation after a proximal phalanx fracture is a serious complication that can be prevented with a careful clinical and radiographic evaluation and appropriate treatment. If a malunion does occur, a corrective osteotomy can be performed to restore proper hand function .   Malrotation is a potential complication following a proximal phalanx fracture that can significantly impact hand function. Here is a breakdown of its types, causes, and treatment .

22. Types Malrotation is a type of malunion , which is the healing of a bone in an incorrect position. The key characteristic of malrotation is that the finger is twisted out of its normal anatomical alignment. This can manifest as Types * Scissoring or overlapping of fingers during flexion: This is the most common and easily identifiable sign of malrotation . When the patient makes a fist, the injured finger may cross over or under an adjacent finger . * Abnormal cascade: In a normal hand, when the fingers are flexed, they naturally converge towards the same point on the wrist (the scaphoid bone). Malrotation disrupts this normal cascade . * Tilting of the fingernail: The leading edge of the fingernail may be tilted when the fingers are viewed end-on . :

23. Causes Malrotation can occur even with seemingly minor fractures. The deforming forces acting on the proximal phalanx, combined with the difficulty of assessing rotational alignment, can contribute to this complication . * Deforming forces: The proximal fragment of the fractured phalanx is often flexed by the interossei muscles, while the distal fragment is extended by the central slip of the extensor tendon. This creates an unstable fracture pattern that is prone to malalignment .

24. Base Fractures * Expected Angulation: Apex dorsal angulation is the typical deformity . * Deforming Forces: The central slip of the extensor tendon pulls the proximal fragment into extension, while the flexor digitorum superficialis (FDS) pulls the distal fragment into flexion. This results in the characteristic apex dorsal angulation. This type of fracture is often unstable and may require surgical fixation to prevent a hyperextension deformity .

25. Shaft Fractures Shaft Fractures: Breaks in the middle of the bone, which can be straight across (transverse), angled (oblique), or twisting (spiral) . * Expected Angulation: Apex volar angulation is the most common deformity . * Deforming Forces: The powerful intrinsic muscles of the hand ( interossei and lumbricals ) insert on the base of the proximal phalanx and pull the proximal fragment into flexion. At the same time, the central slip of the extensor tendon pulls the distal fragment into extension. This combination of forces creates the apex volar angulation. If left uncorrected, this can shorten the extensor tendon mechanism, leading to a loss of full extension at the PIP joint .

26. Condylar Fractures Head/Condylar Fractures: Breaks at the end of the bone closest to the fingertip, often involving the joint * Expected Angulation: Condylar fractures can be unicondylar (one condyle) or bicondylar (both condyles). They often result in angulation of the finger itself, usually laterally or medially, as one of the condyles is displaced . * Deforming Forces: These fractures are typically caused by axial loading combined with lateral angulation of the finger. The deforming forces are primarily compressive and shearing forces at the joint level. Due to their intra-articular nature and tendency to be very unstable, condylar fractures almost always require surgical intervention to restore the articular surface and prevent long-term angular deformity and joint stiffness .

27. Inadequate reduction and fixation: If the fracture is not properly reduced (set) and stabilized, rotational deformity may not be corrected . * Difficult assessment: Unlike angulation, which is often visible on X-rays, rotational deformity can be difficult to detect on standard radiographs. Clinical examination is crucial, and it's best done by assessing the finger cascade with the hand in a flexed position. A common mistake is to assess for malrotation with the fingers in full extension, where the deformity may not be apparent . * Delayed treatment: In children, especially, a proximal phalanx neck fracture can be missed initially, leading to malunion and a functional deficit . * Specific fracture patterns: Spiral and oblique fractures, which are caused by twisting injuries, are particularly prone to malrotation .

28. Treatment of complications The treatment for malrotation it depends on whether the fracture is acute (immediately after the injury) or a malunion (after the bone has healed incorrectly) . Acute Treatment The goal is to prevent malrotation from occurring in the first place . * Reduction: The fracture is manually reduced, often under anesthesia, to correct any angulation or rotation . * Fixation: Once the fracture is reduced, it must be stabilized to prevent it from redisplacing . This can be done with : * Nonoperative treatment: For stable fractures with minimal displacement and no malrotation , splinting may be sufficient. The hand is typically placed in an "intrinsic plus" position (wrist in neutral or slight extension, metacarpophalangeal (MCP) joints in 90 degrees of flexion, and proximal interphalangeal (PIP) joints in extension) .

29. * Surgical fixation: For unstable fractures, surgical intervention is necessary. This may involve using pins (K-wires), screws, or plates to hold the bone fragments in the correct position while they heal . * Intraoperative assessment: During surgery, it is essential to check the rotational alignment by flexing the finger and observing the cascade. This helps ensure that the malrotation is corrected before the fixation is finalized .

30. Treatment for Malunion If malrotation is diagnosed after the fracture has healed (a malunion ), a surgical procedure called a corrective osteotomy is often required . * Surgical procedure: An osteotomy involves cutting the bone and reorienting it to correct the rotational deformity. This is typically done at the level of the phalanx or the metacarpal, depending on the specifics of the case . * Fixation: After the bone is cut and derotated , it is fixed in its new, corrected position using plates and screws . * Rehabilitation: Postoperatively, aggressive hand therapy is crucial to restore motion and function to the finger. Stiffness is a common complication, and therapy helps to minimize this .

31. Fractures and dislocations involving the hand are classified as Appropriate treatment is determined according to the stability of fracture. Stable fractures are those that would not displace if some degree of early digital motion were allowed. Unstable fractures are those that displace to an unacceptable degree if early digital motion is allowed. Although some unstable fractures can be converted to stable fractures with closed reduction, it is difficult to predict which of these will maintain their stability throughout the early treatment phase. For this reason, most unstable fractures should undergo closed reduction and percutaneous pinning or open reduction internal fixation (ORIF) to allow early protected digital motion and thus prevent stiffness .

32. Most metacarpal and phalangeal fractures can be treated nonoperatively using closed methods that emphasize alignment and early protected motion . All splinting programs for metacarpal or phalangeal fractures recognize the need to position the metacarpophalangeal joints in flexion to avoid extension contractures . The thumb metacarpophalangeal is not exempt from this rule, and many stiff thumbs result from hyperextended thumb spica immobilization . * The interphalangeal joints typically are rested in full extension .