This was a prospective study done over a two year period from December 2008 to December 2010. The total number of patients in the study was 21 with 26 phalangeal fractures. Data were collected from Government Chengalpattu Medical College Hospital, Chengalpattu during the period of December 2008 to December 2010. This study was carried out in collaboration with the departments of Casualty, General Surgery, Orthopaedics, Radiology, Anaesthesia, and Physiotherapy. An informed written consent was taken before carrying out any diagnostic or surgical procedure. All the investigations required were routinely done during the admission period or prior to it. X-rays of the involved hand-anteroposterior and oblique views were taken in all the cases, preoperatively as well as postoperatively. The proforma was prepared, duly filled and the results analysed.

The inclusion criteria were closed unstable phalangeal fractures and multiple phalangeal fractures. The exclusion criteria were mangled extremities or major crush injury, flexor or extensor tendon injury, associated bone loss, thumb and metacarpal fractures.

Every patient was explained regarding the procedure. Axillary block was given along with musculocutaneous nerve block. A manual pneumatic tourniquet was applied and time noted. The involved upper limb was placed on the hand table. A dorso-lateral incision was made and deepened in layers. The extensor tendon was either retracted to one side or split in the middle to expose the proximal or middle phalanx. Using a small periosteal elevator, the periosteum was elevated. With the help of the Howarth’s elevator, the soft tissue interposition between the fracture fragments was cleared. The fracture was reduced and held in alignment with bone holding forceps. These fractures were fixed with stainless 2.0 mm 2 hole or a 4 hole plate with spacer and 2.0×8 mm screws. Using a micromotor and a 1.5 mm burr, drill holes were made proximal and distal to the fracture site. Holding the plate in situ, the screws were driven into the holes with a 2 mm screwdriver with sleeve. Anatomic or near anatomic (<1-mm articular step-off) reduction and stable fixation were achieved in all patients at the time of surgical treatment. Tourniquet was released and haemostasis was secured with bipolar diathermy. If the extensor tendon had been split, it was approximated with 4-0 prolene intermittent sutures. Skin was closed with 3-0 prolene interrupted mattress sutures over two Segmuller drains. Dressing was done with paraffin gauze, dry gauze and finger crepe bandage. A volar below elbow splint was applied with wrist in neutral or 10 degrees extension, metacarpophalangeal joints in 90 degrees of flexion and interphalangeal joints straight. A sling was applied to support the anaesthetized upper limb.

Patient was shifted out to the postoperative ward. Patient was kept nil by mouth for 2 hours following which orals were allowed. Patients were put on parenteral antibiotics and analgesics. On postoperative day 1, the suture line was inspected and the patient was sent for check x-ray of the involved hand-anteroposterior and oblique views.

The average follow-up period was 12 (range, 4-24) weeks. The average time to fracture healing was 4.7 (range, 3-6) weeks. Early active motion was initiated after 1 week following surgery. Range of motion of the affected digit was measured with a use of a standard goniometer and evaluated as a proportion of Total Active Motion (TAM). Results were considered excellent, good, or poor according to criteria defined by Belsky MR et al., at 2 months postoperative [16]. Twenty one patients (84.6%) had an excellent result.

Over a period of 24 months, a total of 21 patients with 26 fractures of proximal and middle phalanges were studied. There were 21 fractures of the proximal phalanx and 5 fractures of the middle phalanx. Seventeen patients had single fractures of either the proximal or middle phalanx, whereas 4 patients had multiple fractures (3 had fractures of two phalanges and 1 had fractures of 3 phalanges). Out of the 26 fractures, 16 were right sided whereas 10 were left sided. There were 18 males and 3 females in the study group. There were 6 patients in age group of 21-30 years, 9 patients in 31-40 years, 4 patients in 41-50 years and 2 patients in 51-60 years age group. Of the 21 patients, 13 fractures were due to RTA, 6 were due to assault and 2 were due to fall on the hand. There were 2 fractures involving the head, 3 neck, 16 shaft and 5 fractures involving the base. Eighteen fractures were of transverse type, 4 oblique, 2 spiral and 2 were comminuted [Table/Fig-1].

Complications: 2 Patients had stiffness, 3 had infection and 1 patient had PIP joint extensor lag [Table/Fig-2].

[Table/Fig-2]:

Pie diagram showing the complications of phalangeal fractures.

Out of the total of 26 phalangeal fractures in the study, 22 (84.6%) had excellent or good results and 4 (15.4%) had poor results following rigid skeletal stabilisation by plate and screw technique, according to the Belsky’s criteria [Table/Fig-3,4,5,6,7 and 8].

[Table/Fig-3]:

a) Communited fracture shaft of proximal phalanx rt. middle finger; b) Fracture fixed with 2.0 mm 4 hole plate and screws.

[Table/Fig-4]:

a) S-shaped incision marked; b) Lazy s incision made; c,d) Extensor tendon identified and retracted laterally to expose fracture; e) ORIF done; f) Extensor tendon placed back in position; g) Fracture fixed with miniplate and screw; h) Excellent total active motion (Belsky’s criteria).

[Table/Fig-5]:

a) Closed transverse fracture shaft of proximal phalanx rt. ring finger; b) Proximal phalanx fracture; c) X-Ray showing good alignment.

Phalangeal fractures are commonly encountered fractures in hand [1]. Majority of them are stable and can be treated non-operatively. Unstable fractures as those with shortening, angulation, deformity or segmental fractures need operative intervention [5,6]. Achieving fracture stability to facilitate early mobilisation to achieve a full functional recovery of the hand as early as possible is the main aim of operative fracture fixation [5,17].

The ASIF manual recommends removing K-wires after 1-2 months and screws and plates at 4-6 months postoperatively, yet Dabezies EJ and Schutte JP report no ill effects in patients whose hardware was still in place long after surgery [18]. Freeland A and Jabaley M studied 68 minicondylar plate applications in the metacarpals and phalanges [19]. They found that approximately one third of patients had excellent final range of motion, one third had good or fair range of motion, and one third had poor range of motion. The complication rate was significantly higher in open fractures, in fractures with associated soft-tissue injury, and in fractures requiring bone grafting.

Black D et al., found that dorsal plating, with or without lag screws, provided a much more stable reduction than wire techniques in phalangeal fractures [20]. Vanik RK et al., compared the strength of various internal fixation techniques in the treatment of metacarpal fractures [21]. They concluded that plate or plate-and-screw fixation was sufficiently stable to withstand functional use of the hand, but neither a single K-wire nor crossed K-wires provide solid fixation when measured against intraosseous wire, plating, and combination intraosseous wire and K-wire.

A recent study compared the biomechanics of the hand following application of either microplates or miniplates to fractures of the metacarpal or phalanges. The authors concluded that dorsally applied miniplates provided the greatest rigidity across a fracture to a dorsal load [22]. Freeland A and Jabaley M, discuss the advantages and disadvantages of rigid internal fixation in the hand [19]. Screws and plates are said to enhance stability of the reduction by increasing friction between the fracture fragments while freeing the hand for early mobilisation. When properly used, rigid fixation devices are stress shielding, applying the load to the implant rather than to the fracture site [19,23-26]. Fracture of the phalangeal neck is mainly seen in children and is generally missed on X-rays. The fractures are usually categorised into undisplaced, partialy displaced and completely displaced, requiring ORIF [27].

The patients were limited in the two year period to compare with K-wire fixation of the fractures. These plates were all stainless steel due to affordability factor and hence usage of titanium plates and their results couldn’t be done.

Rigid skeletal stabilisation of proximal and middle phalangeal fractures of the hand by open reduction and internal fixation using plate and screw technique seems to be an effective treatment method for these unstable fracture patterns.