Proximal Phalanx

Middle Phalanx

Transverse Fractures

• Perpendicular to long axis
• Unstable due to lack of interdigitation
• K-wire or plate fixation

Short Oblique Fractures

• 30-45 degree angle
• Unable to lag screw (too short)
• K-wire or plate fixation

Long Oblique/Spiral Fractures

• Greater than 45 degree angle
• Amenable to lag screw fixation
• 2-3 screws minimum

Comminuted Fractures

• Multiple fragments
• Plate fixation to bridge
• May need bone graft

Treatment Approach: Comminuted fractures require bridge plating with fixation proximal and distal to the comminuted zone.

Unicondylar Fractures

• Single condyle avulsed
• Collateral ligament attached
• Angular deformity if untreated
• Require ORIF

Bicondylar Fractures

• Both condyles separate
• Articular comminution common
• Mini-condylar plate often needed

Pilon Fractures (MP Base)

• Impaction pattern
• Central depression
• May need external fixation with ligamentotaxis

Management Strategy: These challenging fractures often benefit from ligamentotaxis using distraction techniques.

Non-Operative Treatment

Indications:

• Stable, non-displaced fractures
• Acceptable alignment maintained
• No rotational deformity
• Patient compliance expected

Techniques:

1. Buddy Taping:

• Tape affected finger to adjacent finger
• Provides stability through adjacent digit
• Allows early motion
• Ideal for stable fractures

2. Extension Block Splinting:

• For base fractures with dorsal angulation
• MCP in 70-90 degrees flexion
• Prevents dorsal displacement

3. Alumifoam Splint:

• Custom molded
• Immobilizes fracture
• Allows motion of unaffected joints

Protocol:

• Immobilization: 3-4 weeks
• Begin ROM exercises early when stable
• Buddy tape for protection 4-6 weeks total
• Hand therapy referral for optimal outcomes

Key Success Factor: Early mobilization when fracture stable prevents stiffness complications.

Operative Treatment

Surgical Indications:

• Rotational deformity
• Unacceptable angulation
• Shortening greater than 3mm
• Intra-articular fractures (displaced)
• Unstable fracture pattern
• Open fractures
• Multiple fractures
• Associated tendon/ligament injury

Fixation Selection Principles:

Choose fixation based on fracture pattern:

• Transverse/short oblique: K-wires or plate
• Long spiral: Lag screws (2-3 minimum)
• Comminuted: Plate to bridge
• Condylar: ORIF with screws or mini-plate

Critical Decision Point: Any rotational malalignment mandates surgical intervention regardless of fracture pattern.

Percutaneous K-Wire Fixation

Indications: Transverse, short oblique, pediatric

Techniques:

• Cross K-wires (most stable)
• Longitudinal K-wires (less stable)
• Bouquet technique (multiple wires)

Advantages:

• Minimal soft tissue dissection
• Simple removal
• Cost-effective

Disadvantages:

• Pin site infection
• Pin migration
• May need external protection

Technical Points:

• Cross wires provide better rotational control
• Cut and bend wires outside skin
• Remove at 3-4 weeks

Post-Fixation Care: Pin site monitoring and early motion of adjacent joints while fracture protected.

Lag Screw Fixation

Indications: Long oblique/spiral fractures (length at least 2x diameter)

Technique:

• 1.5mm or 2.0mm cortical screws
• Minimum 2 screws (preferably 3)
• Perpendicular to fracture line
• Lag technique for compression

Advantages:

• Excellent compression
• May allow early motion
• Low profile

Disadvantages:

• Limited to specific patterns
• Technically demanding

Critical Technical Points:

• Screws perpendicular to FRACTURE line (not bone axis)
• Minimum 2 screws for rotational control
• Engage 6 cortices minimum per screw

Biomechanical Principle: Compression across fracture site promotes primary bone healing and allows early motion.

Plate Fixation

Indications: Transverse, comminuted, multiple fractures

Options:

• 1.5mm or 2.0mm mini-plates
• Condylar plates (head fractures)
• Lateral or dorsal placement

Approaches:

• Lateral: Between NV bundle and extensor (PREFERRED)
• Dorsal: Split extensor mechanism
• Volar: AVOID (tendon adhesions)

Advantages:

• Strongest fixation
• Allows immediate motion
• Good for comminution

Disadvantages:

• More soft tissue dissection
• Tendon adhesions possible
• Hardware prominence

Technical Considerations:

• 3 screws proximal and distal to fracture minimum
• Bicortical purchase essential
• Contour plate carefully to bone

Key Advantage: Rigid fixation allows immediate active motion, reducing stiffness risk significantly.

External Fixation

Indications: Severely comminuted, open fractures, pilon-type

Technique:

• Mini-external fixator
• Pins in adjacent bone/phalanx
• Distraction for ligamentotaxis

Advantages:

• Minimal soft tissue trauma
• Ligamentotaxis for reduction
• Good for severe comminution

Protocol:

• Maintain distraction for 3-4 weeks
• May allow early motion with dynamic frame
• Remove when fracture sticky (4-6 weeks)

Indication Rationale: Used when internal fixation not feasible due to severe soft tissue injury or bone loss.

Surgical Approaches

Dorsal Approach:

1. Longitudinal incision over phalanx
2. Identify extensor mechanism
3. Split between central slip and lateral bands (PP)
4. Direct access to dorsal cortex

Lateral Approach (Preferred):

1. Mid-lateral incision
2. Identify NV bundle (volar)
3. Identify lateral band (dorsal)
4. Access between structures
5. Less extensor tendon dissection

Key Principles:

• Preserve extensor mechanism when possible
• Protect digital nerves
• Avoid volar approach (tendon adhesions)

Approach Selection: Lateral approach preferred for most plating to minimize extensor mechanism trauma and adhesion risk.

Cross K-Wire Pattern (Most Stable)

1. Setup: Fluoroscopy, mini C-arm, 0.045" or 0.062" K-wires
2. Reduction: Achieve closed reduction, hold with reduction forceps
3. First wire: Insert dorsal-lateral, aim distal-medial, cross fracture site
4. Second wire: Insert dorsal-medial, aim distal-lateral, cross first wire
5. Check: PA and lateral fluoroscopy for reduction and wire position
6. Finish: Cut and bend wires outside skin, apply dressing

Intramedullary Bouquet Technique

1. Used for transverse fractures
2. Multiple 0.028" K-wires inserted retrograde from fracture site
3. Drive across fracture into proximal fragment
4. Provides rotational and angular stability
5. Wires buried beneath skin

Advantage: Wires buried beneath skin, reducing pin site infection risk compared to percutaneous technique.

Indications

Long oblique/spiral fractures (length at least 2x diameter)

Technique

1. Approach: Lateral approach to visualize fracture
2. Reduction: Anatomic reduction with bone clamps
3. Provisional fixation: 0.028" K-wire for temporary stability
4. Screw selection: 1.5mm or 2.0mm cortical screws
5. Drilling: Gliding hole in near cortex, thread hole in far cortex
6. Screw insertion: Perpendicular to fracture line, 2-3 screws minimum
7. Compression: Tighten sequentially for interfragmentary compression
8. Check: Fluoroscopy for reduction, rotation assessment

Key Technical Points

• Screws perpendicular to fracture (not to bone axis)
• Minimum 2 screws (preferably 3) for rotational stability
• Engage 6 cortices minimum per screw
• Check rotation before and after fixation

Critical Success Factors: Achieving adequate compression and rotational control depends on proper screw placement and number.

Indications

Transverse, short oblique, comminuted fractures

Lateral Plating Technique

1. Incision: Mid-lateral incision over phalanx
2. Dissection:
   • Identify NV bundle (retract volarly)
   • Identify lateral band (retract dorsally)
   • Expose lateral cortex
3. Reduction: Reduce fracture, hold with bone clamps
4. Plate selection: 1.5mm or 2.0mm mini-plate
5. Plate application:
   • Contour plate to lateral surface
   • 3 screws proximal and distal to fracture minimum
   • Bicortical screw purchase
6. Closure: Careful soft tissue closure, avoid tension

Dorsal Plating Technique

1. Incision: Dorsal longitudinal incision
2. Extensor mechanism: Split centrally or between central slip and lateral band
3. Plate application: Low-profile plate on dorsal surface
4. Risk: Extensor tendon adhesions (consider lateral approach instead)

Condylar Plating Technique

For head fractures:

1. Mini-condylar plates (L-shaped or T-shaped)
2. Restore articular congruency first
3. Provisional K-wire fixation
4. Apply plate to support reconstruction
5. Lag screws for condylar fragments

Critical Goal: Anatomic articular reduction prevents post-traumatic arthritis and joint stiffness.

Indications

Severe comminution, open fractures, pilon-type

Technique

1. Frame selection: Mini-external fixator or dynamic fixator
2. Pin placement:
   • Proximal pins in metacarpal or proximal phalanx base
   • Distal pins in distal phalanx or middle phalanx
3. Reduction: Ligamentotaxis through distraction
4. Fixation: Lock frame in reduced position
5. Dynamic protocol: May allow early motion through hinged frame

Key Principle: Ligamentotaxis uses soft tissue tension to reduce and maintain alignment in severely comminuted patterns.

Postoperative Care

Week 0-1: Protection Phase

Goals:

• Wound healing
• Control edema
• Protect fixation

Protocol:

• Splint protection (volar slab with MCP in flexion)
• Hand elevation above heart level
• Ice therapy 20 minutes every 2 hours
• Digital ROM exercises if fixation is rigid (plate/screws)
• K-wire cases: splint immobilization
• Monitor for infection (increased pain, erythema, drainage)

Wound Care:

• Dressing change at 2-3 days
• Suture removal at 10-14 days
• Pin site care (K-wires): daily cleaning with chlorhexidine

Week 1-3: Early Motion Phase

Goals:

• Prevent stiffness
• Maintain reduction
• Progress ROM

Protocol:

• Remove sutures at 10-14 days
• Hand therapy referral
• Active ROM exercises:
  • MCP, PIP, DIP flexion/extension
  • Tendon gliding exercises
  • Place and hold exercises
• Avoid passive stretching initially
• Splint between exercises
• Edema control: compression glove, elevation, retrograde massage

K-Wire Management:

• Continue splint protection
• Active ROM of adjacent joints
• Pin site monitoring

Week 3-6: Progressive Motion Phase

Goals:

• Increase ROM
• Begin light functional use
• Remove K-wires if used

Protocol:

• Remove K-wires at 3-4 weeks (when fracture sticky)
• Increase frequency of ROM exercises
• Begin passive ROM (gentle)
• Dynamic splinting if stiffness developing:
  • Extension turnbuckle for PIP flexion contracture
  • Flexion strap for extension lag
• Light functional activities
• Buddy taping for protection

Radiographic Follow-up:

• XR at K-wire removal to confirm alignment maintained
• Check for callus formation

Week 6-12: Strengthening Phase

Goals:

• Restore grip strength
• Return to function
• Maximize ROM

Protocol:

• Progressive strengthening exercises:
  • Putty exercises (soft to firm progression)
  • Gripper exercises
  • Functional activities
• Sport-specific training
• Work conditioning program
• Continue ROM exercises to plateau

Return to Activities:

• Desk work: 1-2 weeks (with protection)
• Light manual work: 6-8 weeks
• Heavy manual work: 10-12 weeks
• Contact sports: 10-12 weeks (with protection initially)

Hardware Removal

Indications for Removal:

• Symptomatic hardware (prominence, pain)
• Patient request
• Plate/screw removal: generally only if symptomatic

Timing:

• K-wires: 3-4 weeks routine
• Screws/plates: after fracture consolidation (12+ weeks) if needed

Red Flags Requiring Review

• Increasing pain after initial improvement
• Loss of reduction on radiographs
• Signs of infection (erythema, purulent drainage, fever)
• Worsening stiffness despite therapy
• Neurovascular compromise
• Pin migration or loosening