Middle phalanx fracture - undisplaced
Some middle phalanx fractures require surgery and some don't.
If your middle phalanx fracture is undisplaced (ie if the fragments are still in their normal position) it is unlikely that you will need surgery. Your fracture will be treated with splinting, taping or casting (or a combination of all three). Generally a cast is only used for treating middle phalangeal fractures if the patient is a child or someone who will not be able to manage with a splint. The disadvantage of a cast is that you cannot remove it to exercise your fingers, so your joints may become stiff. Wearing a splint allows you to protect the fracture while it is still healing, but allows you to remove the splint to perform the finger exercises prescribed by your hand therapist. If you are able to keep the joints mobile this means that when your fracture is strong enough to allow full use of your hand then you won't be limited by stiffness - so your rehabilitation time is faster.
The speed of fracture healing can be affected by factors such as the type of fracture, your health and your ability to comply with therapy. Usually it is safe to start gentle exercises in a finger with an undisplaced fracture at 3-4 weeks. Speak with your surgeon and hand therapist to determine what is the right time for you, and what sort of exercises you should perform. You will be permitted to do light activities (such as eating a meal) before the fracture is fully healed. At 6 weeks after the fracture you are usually safe to use your hand for most activities. You will usually be advised to avoid heavy loads or contact sports until 8 weeks. Often you may be advised to strap your injured finger to another finger for support when you initially stop wearing your splint, or during the first few weeks of activity. Your surgeon and hand therapist will advise what is best for you.
Middle phalanx fracture - displaced or unstable
If a middle phalanx fracture is displaced or if the fracture pattern is deemed "unstable" it is usual that surgery will be recommended. If you need surgery it is best that this be performed within 2 weeks of your fracture. Displaced fractures are likely to heal with shortening, or angulation, or rotation of your finger. These three problems can lead to functional problems with your hand, because your finger will not move in the normal way once the fracture heals.
Surgery to fix the fracture can be done in a variety of ways. In some instances your surgeon may tell you about two different ways, and seek your input on which you think would work best for you. Generally your doctor will recommend one particular type of surgery taking into consideration your injury and factors like your occupation, hand dominance, hand use and preferences.
Middle phalanx intra-articular fracture
Intra-articular fractures involve the joint surface. It is very important that intra-articular fractures are treated properly to reduce the risk of post traumatic osteoarthritis. Generally speaking, if the joint fragments are displaced by more than 1mm it will be recommended that you have surgery, because an irregular joint surface carries a high risk of subsequent arthritis.
In most instances surgery is successful in realigning the joint surfaces. If the joint surface is broken into multiple small fragments it is very difficult to repair the joint. If the joint cannot be successfully repaired the subsequent options may include
- living with a stiff or painful joint
- having a joint fusion (a fused joint is not painful, but it does not move)
- having a joint replacement
- having a hemi-hamate arthroplasty, which is a bone graft to replace a portion of the middle phalanx articular surface; this only applies to specific types of fractures (click here to read a description and see photos of this procedure)
Types of surgery for middle phalanx fractures
The type of surgery that is performed differs and is largely determined by the type of fracture. The common options are:
- Closed Reduction (this is commonly referred to as a "GAMP", which stands for "General Anaesthetic, Manipulation and Plaster)
This involves manipulation of the fracture under anaesthetic (either local anaesthetic, sedation or general anaesthetic). The displaced fracture is pulled back into position and the fracture is held in position with a splint or cast. This method of treatment is not suitable for unstable fractures, as these fractures will not be able to be held in position with a splint or cast. You will be permitted to start gently moving the finger at 3-4 weeks after the manipulation.
- General Anaesthetic Manipulation and Plaster (GAMP) and K-wire
This involves manipulation of the fracture under anaesthetic. The displaced fracture is manipulated into position and temporary K-wires are inserted through the skin to hold the bone fragments in the correct position. A splint or plaster is then applied. The K-wires are usually removed at 3-6 weeks after surgery. While the K-wires are inside you it is not permissible to move the affected finger, because the wires can bend or break, or cause injury to tendons. Once the wires are removed you will be permitted to start gently moving your finger.
- Open Reduction and Internal Fixation (ORIF)
If you have a displaced or unstable fracture then ORIF treatment is commonly recommended. This surgery involves using screws, or a plate and screws, to hold the bone fragments together solidly. Early movement of the finger is recommended after ORIF treatment to prevent stiffness that can result from scar tissue forming in the tissue planes that were traversed in the surgery. It is still necessary to wear a splint to prevent the finger from forces that could pull apart the metal fixation, but you are able to keep your joints supple through regular gentle exercise. As the fracture heals you are able to put increasing force through the fracture. You are usually able to commence full activities at 6-8 weeks.
Image credit: hand skeleton and plate/screw images created with DrawMD.