Definition
Fractures of the finger occur in the bones called phalanges.
Pathology
The hand has 14 phalanges, which are tubular bones extending from the metacarpal bones to the fingertips. Finger phalanges include the proximal, middle and distal phalange. Besides the thumb with two of them, the other fingers have three phalanges. Phalanges are separated by a set of joints that articulate each bone with the adjacent bone. Fractures of the fingers' phalanges account for up to 10% of all fractures. Although they may be considered less severe compared to other bone fractures, finger fractures can generate significant complications and even disabilities. They can be located at the distal, middle or proximal phalange. Within the phalanges, fractures may be positioned in the neck, just below the head (more frequently), along the shaft or at the base. Depending on the energy applied to the hand, finger fractures may involve injuries to the cartilage, joint capsule, tendons, ligaments, palmar fascia, the dorsal hood as well as the nerves.
Classification
Fractures of the distal phalanges are the most common. They often result from crush injuries to the tip of the fingers leading to blood accumulation below the nail or subungual haematoma, soft tissue injuries, nail bed damage and open lesions. Following crush injuries, amputations of the distal phalange are relatively frequent.
Distal phalange fractures comprise:
Distal tuft fractures: mostly at the finger extremity, often being open fracture caused by crush injury (hammer)
Shaft fractures: located at the central portion of the distal phalange
Middle and proximal phalange fractures comprise:
Transverse fracture caused by axial compression resulting into unstable fractures (blow on the bent knuckle, or to the extremity of the finger)
Oblique fracture from a bending force (sport, catch finger in door) causing malrotation
Spiral fracture following finger twisting, often displaced and unstable
Comminuted fracture of the proximal phalange head (fall on knuckle) requiring surgery. These fractures can be associated with a tear of the flexor tendon.
Finger fractures are also classified in relation to the phalangeal joints:
Extra-articular fractures: occur in the phalange shaft distant from the joints leading to rotational deformity (malrotation)
Intra-articular fractures: located at the phalangeal joint surfaces.
Causes
Finger fractures are caused by a variety of mechanisms, which put axial forces to the fingers. They include crush injuries, a direct blow of a hard object onto the fingers or torsion energy. The most common causes are:
Catching a ball in sports (football, basketball, soccer, rugby)
Catching fingers in carpentry machineries (mixers, saws)
Crush injuries (car doors, hammers)Falls onto fingers/hands
Other forms of direct blows (sport bats)
Risk factors
The following activities represent the main risk factors possibly leading to finger fractures:
Contact sports and ball sports (football, basketball, rugby)
Bat sports (hockey, cricket)
Maneuvering of tools and machineries (mixers, saws)
Boxing
Symptoms
The symptoms arising from finger fractures include:
Pain
Swelling
Bruising
Lacerations
Movement restriction
Hand deformity
Knuckle asymmetry/depression
Diagnosis
A suspected fracture to the fingers should be assessed immediately after an injury has occurred and treated accordingly. The clinical evaluation begins with the medical history of the patient to then focus on the mechanisms of injury. The examiner will determine:Changes in the anatomy of the affected finger(s) against the healthy fingers
Presence of skin lacerations
Digit malrotation when closing the fist
Tenderness with axial compression of the finger
X-rays are taken under antero-posterior, lateral and oblique view to better assess the fracture characteristics. CT scan and MRI scans may be required in case of complex fractures to identify possible damage to soft tissues and ligaments.
Treatment
Nonoperative treatment
Management of finger fractures varies in relation to the fracture site and characteristics. In case of a stable fracture without misalignment surgery is not required and treatment with a hand cast or splint provided with a metal finger extension will last for 3-4 weeks. Sometimes a closed reduction is necessary to re-align the fractured phalanges. Unstable fractures are immobilised with a cast to maintain a functional position of the hand and facilitate correct bone healing. Immobilisation of the fractured finger with a 50-70 degree flexion is used especially with the associated fracture of the metacarpal head. Additional management includes:
Finger taping (healthy finger or buddy, with fractured finger)
Rest
Hand elevation
Ice pads
Painkillers
Administration of NSAIDs
Physiotherapy with gentle finger exercises whilst the hand is in a cast or splint
Surgical treatment
Surgery is required in significantly displaced, or comminuted phalangeal fractures especially when the joints are involved. Different methods are available for fixation depending on the type of fracture:
Open reduction and internal fixation (ORIF) is done in displaced fractures with placement of screws, plates, intramedullary pins and k-wires.
External fixation is used in unstable fractures. A closed reduction with percutaneous pining using k-wires is also a frequent option.
Complications
Complications after finger fracture include:
Non-union of the phalanges or inter-phalangeal joints, if fractures are neglected, treated too late, or in very unstable fractures. This leads to finger misalignment and improper finger rotation
Finger stiffness
Damage to nerves and vessels
Infection (open fractures or after surgery)
Rehabilitation
With or without surgery, a cast or splint is worn for 3 weeks after a finger fracture. The prognosis depends on the severity of the fracture. Physical activities should commence as soon as possible to prevent stiffness of the finger joints. This includes guided movements of the wrist, hand and fingers. A physical or occupational therapist will recommend exercises to restore flexibility and strength of the fingers. Education is critical to inform the patient on how to modify activities to avoid recurrent injuries. Rehabilitation includes:
Finger taping
Massage
Joint mobilisation
Stretches
Electrotherapy
Ball exercise
Activity modification advice
Return to activity plan
Prevention
In order to prevent finger fractures, it is suggested to reduce the risk of falls and protect the hand during physical activities that expose the hands. For those individuals who had previous finger fractures, it is critical to avoid recurrent injuries. Common preventive strategies are:
Finger taping
Use of hand protective gear in sport and carpentry work
Implementation of occupational health and safety regulation in the workplace
Use of devices to improve elderly patient stability and avoid falls
Modification of physical activities
Exercise to improve fingers’ flexibility and posture