A 45-year-old male presents to the emergency department (ED) with right hand pain after an e-bike accident. Physical exam shows deformity and tenderness at the 5th proximal phalanx. Radiographs are shown above (Image 1: Plain radiography of right hand with AP and oblique views. Author’s own images). What is the most likely diagnosis? What are the important aspects of the associated physical examination? What is the management in ED, including pain management? When do you consult orthopedics?
In the above radiographs there is a fracture of the proximal diaphysis of the 5th proximal phalanx, with volar apex angulation and 2 mm of displacement.
- Pearl: Phalanx fractures are very common; they account for 10% of all fractures and 1.5% of all ED visits. The distal phalanx is most commonly fractured, followed by proximal, then middle [1,2].
Perform a neurovascular exam, including two-point discrimination and capillary refill . Assess for rotational alignment by comparing the fingers to each other as well as the other hand. When the fingers are flexed at the MCP and PIP, all four fingernails should be parallel and point towards the scaphoid [1,3].
- Stable, non-displaced transverse fractures can be managed with buddy-taping and early protected motion after pain and swelling subside [1-5].
- Displaced fractures require closed reduction and splinting in the ED [1,3]. The fracture should be immobilized in a gutter splint in the “intrinsic-plus” position with 30° of wrist extension and 90° degrees of MCP flexion (Figure 2) [1,2,5]. SplintER has a great summary of splinting information.
- Pearl: Proximal phalanx fractures are often unstable with apex volar angulation and shortening. [1-3] The interosseous muscles pull the proximal fracture fragment into flexion, while the extensor apparatus pulls the distal fragment into extension [1,5].
Figure 2: Post-reduction films demonstrate reduction of the proximal phalanx fracture with improved alignment since prior exam. Author’s own images.
Peripheral nerve blocks may be preferred to digital blocks because the injection itself is less painful and it does not distort the tissue at the site of injury . An ulnar nerve block can be utilized for analgesia during procedures in the ulnar sensory distribution such as Boxer’s fracture, 5th phalangeal fractures, and medial hand lacerations .
See Figures 3 & 4 or check out this Trick of the Trade for more information on performing an ulnar nerve block.
- Pearl: Ultrasound-guided blocks have the added benefit of directly visualizing the neurovascular bundle to avoid intravascular injection as well as increasing the success of anesthesia .
Figure 3: Ultrasound images. Left image: The ulnar nerve (N) is seen in the short-axis immediately adjacent to the ulnar artery (A) in the volar aspect of the mid-forearm. Right image: The nerve is followed proximally until the nerve (N) and artery (A) separate. Author’s own images.
Figure 4: Ultrasound images. Left image: The needle (arrow) is seen entering from the left side of the screen, in-plane to the ultrasound transducer. Right image: Infiltration of lidocaine (L) to bathe the ulnar nerve (N). Author’s own images.
As always, call orthopedics emergently if you have an open fracture or neurovascular compromise.
Urgent referral is warranted for any proximal phalanx fracture that is not a closed, stable, transverse fracture with less than 2 mm displacement and less than 10° angulation and rotation [1-5]. Fractures that do not fall into this category usually require open reduction and internal fixation [1,4].
References and Resources:
Don’t forget to check out more orthopedic pearls in our SplintER archives.
- Eiff MP, Hatch RL, Petering RC. Finger Fractures. Fracture Management for Primary Care. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2018: 36-62.
- Kee C, Massey P. Phalanx Fracture. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. PMID: NBK545182
- Mailhot T, Lyn ET. Hand. Rosen’s Emergency Medicine Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 534-569.
- Atkinson R. Hand. DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2009: 1379-1403.
- Lögters TT, Lee HH, Gehrmann S, Windolf J, Kaufmann RA. Proximal Phalanx Fracture Management. Hand (N Y). 2018;13(4):376–383. PMID: 29078727
- Amini R, Javedani PP, Amini A, Adhikari S. Ultrasound-Guided Forearm Nerve Blocks: A Novel Application for Pain Control in Adult Patients with Digit Injuries. Case Reports in Emergency Medicine. 2016;2016:2518596. doi: 1155/2016/2518596
- Ünlüer EE, Karagöz A, Ünlüer S, Oyar O, Özgürbüz U. Ultrasound-guided Ulnar Nerve Block For Boxer Fractures. The American Journal of Emergency Medicine. 2016;34(8):1726-1727. doi: 10.1016/j.ajem.2016.06.045