Extra-Articular Fractures of the Proximal Phalanges of the Fingers: A Comparison of 2 Methods of Functional, Conservative Treatment

doi:10.1016/j.jhsa.2012.02.017

The Journal of Hand Surgery

Volume 37, Issue 5, May 2012, Pages 889-898

https://doi.org/10.1016/j.jhsa.2012.02.017 Get rights and content

Purpose

For nonsurgical treatment of fractures of the proximal phalanges of the triphalangeal fingers, different dynamic casts have been described. The main principle behind these casts is advancement and tightening of the extensor hood, caused by a combination of blocking the metacarpophalangeal joints in flexion and actively flexing the proximal interphalangeal joints. In contrast to established treatment protocols using functional forearm casts, the Lucerne cast allows for free mobilization of the wrist joint. The purpose of the current multicenter study was to compare the results of conservative, functional treatment using 2 different methods, either a forearm cast or a Lucerne cast.

Methods

Over a 2-year-period, a prospective, randomized, multicenter study was conducted at 4 hospitals in Switzerland. Clinical and radiological results of 66 consecutive patients having 75 extra-articular fractures of the proximal phalanges were recorded through a minimum follow-up of 3 months. Intra-articular and physeal fractures, pathological fractures, open fractures, concomitant injuries of the tendons or collateral ligaments, and accidents more than 7 days before presentation were excluded from the study.

Results

Radiographically, there were no statistically significant differences between the 2 groups in terms of palmar apex angulation and radial or ulnar angulation. There were no differences in total active range of finger motion. Wrist joint motion at the time of cast removal was statistically superior in patients treated with Lucerne cast. However, there were no significant differences in wrist joint motion at 12 weeks of follow-up.

Conclusions

The clinical and radiological results achieved with the Lucerne cast are comparable to those of established treatment. Well-reduced, minimally angulated, or nonangulated fractures of the proximal phalanges of the fingers can be effectively treated using functional casts without immobilizing the wrist.

Type of study/level of evidence

Therapeutic II.

Section snippets

Methods

From September 2008 to September 2010, a prospective, randomized, multicenter study was conducted at 4 hospitals in Switzerland (Lucerne, Chur, Winterthur, and Zurich). According to the study protocol, 66 consecutive patients (32 female, 34 male) with a total of 75 fractured proximal phalanges of the triphalangeal fingers were randomized to a functional, conservative treatment using either a functional forearm cast (group A) or a LuCa (group B). Randomization was based on the day of accident:

Results

Among all patients enrolled, the little finger was fractured most often, with basal transverse fractures predominating (TABLE 1, TABLE 2, TABLE 3, TABLE 4, TABLE 5, TABLE 6). Thirty-two fractures occurred in the dominant hand, and 43 were in the nondominant hand. In 3 patients initially treated with a LuCa, surgery was performed after 7 to 14 days because of loss of initial reduction exceeding the tolerance limits (n = 2) or because a closed concomitant injury of the extensor tendon was

Discussion

Extra-articular fractures of the proximal phalanx of the fingers are common injuries, and they occur most frequently in the little finger.9, 10, 14, 15 The aim of treatment is to achieve bone healing and maximize motion. Four weeks of immobilization has been reported to result in a decrease in function to 66% of normal TAM.¹²

Well-aligned proximal phalangeal fractures of the triphalangeal fingers can be effectively treated using functional, conservative casts.7, 8, 9, 10, 11 The combination of

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Cited by (21)

Evaluating Kirschner wire fixation versus titanium plating and screws for unstable phalangeal fractures: A systematic review and meta-analysis of postoperative outcomes
2024, Journal of Hand and Microsurgery
Unstable phalangeal fractures represent a clinical challenge in hand surgery. The choice of fixation method, whether Kirschner wire (K-wire) fixation or titanium plating with screws, often depends on surgeon preference due to the lack of comprehensive comparative data. This article aimed to compare the postoperative outcomes of K-wire fixation versus titanium plating and screws in the treatment of unstable phalangeal fractures.
This review was conducted according to the PRISMA guidelines for reporting systematic reviews and meta-analyses. A systematic review and meta-analysis of the existing literature was done encompassing PUBMED, EMBASE, Google Scholar, and Cochrane library using the keywords: “K wire/ Kirschner wire”, “titanium plate/ screws”, “Miniplate/ screws”, and “Unstable phalan∗ fracture/ hand fracture”.
After screening 2374 articles, 6 final studies with a total of 414 patients were included. Operative time was significantly shorter with K-wire fixation compared to plating, by a mean difference of -27.03 min [95% CI -43.80, -10.26] (p = 0.02). Time to radiographic union averaged 7.43 weeks with K-wires versus 8.21 weeks with titanium plates. No statistically significant differences emerged between groups for overall complications (p = 0.69), infection (p = 0.47), malunion (p = 0.36), stiffness (p = 0.11), or need for reoperation (p = 0.10).
K-wire fixation demonstrated shorter mean operating time and faster radiographic union versus plating for unstable phalangeal fractures. These findings can guide surgical decisions and emphasize the need for individualized treatment based on fracture type and patient factors.
Use of external fixation for juxta-articular fractures in children
2019, Injury
Citation Excerpt :
In literature, the notion of JAF in children includes extraarticular fractures type Salter-Harris I and II, metaphyseal and, especially, comminuted metaphyseal fractures [1–6]. The term of “juxta-epiphyseal” fractures or “extraarticular Physeal” ones can be found in literature as well [3,7–9]. This type of bone trauma involves physeal tissue injury from relatively minor involvement (Peterson type 1), to progressively more involvement (Peterson type 2 or Salter-Harris 2), to complete transphyseal disruption (Peterson type 3 or Salter-Harris 1) but if the damage to the germinal layer of cells is not absolutely ensured in comparison to intraarticular fractures (Peterson types 4–6) [1,7].
In this article, the use of external fixation in the management of juxta-articular fractures in paediatric patients is discussed. Basic principles of Ilizarov technique are described for distal radial, distal femoral, distal humeral and distal tibial fractures.
Common indications for external fixation in pediatric fractures are comminuted, complicated, and/or open fractures, particularly at the distal humerus, distal radius, distal femur and distal tibia. There are several benefits of external frame fixation in these type of injuries in children. This method avoids additional injury to the growth plate as K-wires are not placed through it. It enables careful reduction without interfragmentary compression and correct anatomic alignment. There is no soft tissue dissection and periosteal blood supply is preserved. External fixation ensures primary fracture stability even in presence of comminution and high adjustment capability. Immediate joint motion and early weight-bearing are further advantages. Joint bridging is an option in severe bone loss or soft tissue injuries.
Lucerne cast – LuCa: Functional conservative treatment of extra-articular fractures of the proximal phalanges of the fingers (with video)
2018, Hand Surgery and Rehabilitation
Citation Excerpt :
Thus, fractures of the distal one-third of the proximal phalanx should be managed like intra-articular fractures. Well-aligned fractures of the proximal phalanges of the triphalangeal fingers can be treated non-surgically using the Lucerne Cast [2–4]. Functional conservative management of those fractures gets around the significant disadvantages of surgical treatment: prolonged finger swelling and adhesion of tendinous structures to the implants and to the bone, likely requiring implant removal and tenolysis in the future.
Most extra-articular fractures of the proximal phalanges (P1) of the triphalangeal fingers can be treated conservatively with good results. Prerequisites for successful fracture treatment are intact soft tissue without any lesions of the extensor hood and stable initial fracture reduction. The key to functional conservative treatment of P1 fractures is to immobilize the metacarpophalangeal joints in flexion, resulting in equilibrium of flexor and extensor forces across the fracture site, which converts these inherently unstable fractures into relatively stable fractures. Precise initial application of the cast and regular follow-up of the patient is essential for successful treatment. By means of an instructional video, an overview of the equipment required is given, and the correct application of a Lucerne Cast is illustrated step-by-step.
La majorité des fractures extra-articulaires de la phalange proximale (P1) des doigts longs peut être traitée orthopédiquement avec de bons résultats. Les prérequis pour réussir le traitement de ces fractures sont une absence de lésion des parties molles et notamment de l’aponévrose de l’extenseur et une réduction initiale stable de la fracture. Le point-clé du traitement orthopédique des fractures de P1 est l’immobilisation des articulations métacarpophalangiennes en flexion, permettant l’équilibre des forces des extenseurs et des fléchisseurs de part et d’autre de la fracture et transformant ces fractures intrinsèquement instables en fractures relativement stables. Une confection initiale parfaite et un suivi régulier du patient sont essentiels au succès de ce traitement. Grâce à une vidéo pédagogique, nous donnons la vision du matériel nécessaire et l’utilisation correcte de l’attelle LuCa est illustrée pas à pas.
Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws
2015, Journal of Hand Surgery
To present the technique, indications, and outcomes of metacarpal and phalangeal fractures fixed with intramedullary cannulated headless screws (CHS).
We retrospectively reviewed all charts of patients whose metacarpal and phalangeal fractures had been treated with intramedullary CHS in our practice. A total of 69 fractures (48 metacarpal and 21 phalangeal) were identified in 59 patients. Seventeen were open fractures. Eleven patients had multiple fractures (29 in total); of those, 21 were managed with CHS. In 4 other fractures the method was abandoned intraoperatively. The defect created by the entrance of the screw in the proximal phalanx was identified by computed tomography in 20 patients.
In 63 fractures a single screw was used; in 6 fractures 2 screws were used to provide stronger fixation. All patients returned to full duties or sport activities at an average of 76 days (range, 3 wk to 15 mo). At the latest follow-up (range, 5–54 mo; average, 19 mo) total active motion was on average 247° (range, 150° to 270°) for all fractures, 249° (range, 210° to 270°) for metacarpal, and 243° (range, 150° to 270°) for proximal phalangeal fractures. All fractures were healed and within acceptable radiological parameters. A comminuted basilar phalangeal fracture displaced secondarily yielding a poor functional result. Two patients required tenolysis and further procedures before the final result was achieved. The screw hole represents around 20% of the proximal phalanx distal articular surface.
Unstable transverse fractures in the phalanx and metacarpal are amenable to single intramedullary CHS fixation. Comminuted fractures require more complex configurations.
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Extra-Articular Base Fractures of the Proximal Phalanx in Adults: A Systematic Review
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Rehabilitation following extra-articular proximal phalangeal fractures of the fingers in adults: a scoping review
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Scientific articleExtra-Articular Fractures of the Proximal Phalanges of the Fingers: A Comparison of 2 Methods of Functional, Conservative Treatment

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Methods

Results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

Injury

J Hand Surg

Ann Chir Main

J Biomech

J Hand Surg

Scientific article
Extra-Articular Fractures of the Proximal Phalanges of the Fingers: A Comparison of 2 Methods of Functional, Conservative Treatment