Vol. 18 • Issue 1 • Page 17
Phalangeal fractures are encountered commonly in the emergency department. Although they represent a common injury of the hand, optimum splinting techniques for the initial immobilization of a finger fracture are not well documented.
Phalangeal fractures account for 23% of all fractures below the elbow.1Phalangeal fractures are nearly twice as common as metacarpal fractures. The proximal phalanx is the most commonly fractured phalanx, followed by the distal phalanx and then the middle phalanx.2The small finger accounts for 38% of all digital ray fractures, with a relatively even distribution across the remaining four rays.2The intrinsic plus position and the position of function are the two methods used for immobilizing a phalanx fracture. Buddy taping is used for stable, neurovascular-intact phalanx fractures that are not dislocated or open. Intrinsic position is achieved when the metacarpophalangeal (MCP) joint is flexed to 90 degrees while the interphalangeal (IP) joints are in full extension and the wrist in 10 to 20 degrees of extension.
Position of function is achieved when the MCP joint is flexed at 70 or more degrees, the proximal interphalangeal (PIP) joint is flexed at 15 degrees and the distal interphalangeal (DIP) joint is flexed from 5 to 10 degrees. Position of function commonly is described as looking as if the patient is holding a beverage can. The wrist should also be in 10 to 20 degrees of extension.
Buddy taping is achieved when the injured phalanx is stabilized by taping it to an uninjured finger adjacent to the compromised collateral ligament.3A piece of Webril is placed between the taped fingers to absorb moisture and to prevent the fingers from rubbing together.
The literature remains unclear as to which splinting technique-intrinsic plus position or position of function-achieves the best outcome. No well performed studies have provided evidence that intrinsic position offers a better outcome than position of function when used as the initial splinting position. Perhaps successful outcome relies more on a quick orthopedic follow-up, within seven days, than on the initial splinting method.
Distal Phalanx Splinting
Tuft fractures and mallet finger are the most common injuries affecting the distal phalanx, and both can be treated with an aluminum foam splint. Tuft fractures usually are stable and can be splinted from the volar PIP, curving up around the distal phalanx.
Mallet finger injuries should be splinted with the DIP in extension or slight hyperextension. The aluminum splint can be applied to the volar surface, extending from the PIP joint to the distal phalanx (Figures 1 and 2). This allows flexion of the PIP joint. Katzman and colleagues have demonstrated that only the DIP joint need be immobilized in extension to allow healing of the mallet finger.4
A neurovascular check completes the splinting. All jewelry should be removed from the extremity.
Middle & Proximal Phalanx Splinting
The treatment of a middle and proximal phalangeal injuries is dictated by stability. Stable injuries (i.e., nondisplaced fractures, absence of intra-articular fracture and an intact joint when stress is applied) to the middle phalanx, proximal phalanx and PIP joint can be treated initially with buddy taping (Figure 3) or aluminum foam splint in the intrinsic plus position (Figure 4) or position of function (Figure 5). All jewelry should be removed from the extremity. A neurovascular exam should be done after splinting.
Unstable injuries (i.e., with deformity; intra-articular fractures involving greater than 20% of the articular surface; with tendon injury; and displaced fractures) of the middle phalanx, PIP joint or proximal phalanx, and injuries of the MCP joint, require either ulnar gutter splinting or radial gutter splinting.
For ulnar gutter splinting, all jewelry should be removed, and the patient should be covered with a sheet to protect from splashing plaster. Stockinette is applied first to protect the skin from the plaster. The stockinette should be cut longer than the splint and trimmed to expose the uninjured fingers. The stockinette should extend past the fingers to be splinted (Figure 6). Webril is placed between the injured finger and the adjacent finger, similar to buddy taping. This keeps the fingers from rubbing and absorbs sweat (Figure 7).
Webril is applied, working from distal to proximal, reaching about one-third of the way down the proximal ulna. The Webril should extend distally past the joint of the injured phalanx. Three to four layers of Webril are placed at the joints, at the bony prominence of the wrist and at the proximal end of the splint. One or two layers of Webril are sufficient for the remaining areas of the hand and forearm (Figure 8). The Webril should be smooth to avoid creating pressure areas. The stockinette should extend beyond the Webril from both ends.
Plaster should be measured to the length of the area covered by Webril; eight to 10 layers of plaster are used. The plaster should be wet with room temperature water. The plaster can be squeezed to remove excess water-oversoaking is not necessary and may remove the plaster. The plaster is applied laterally to the ulna, forming a gutter (Figure 9). The excess stockinette is folded down over both ends of the plaster. An elastic bandage is applied, working distally to proximal (Figure 10). The hand and fingers should be placed in the intrinsic position and held until the splint hardens (Figure 11). A neurovascular check should be completed after splinting.
Radial gutter splinting is similar to ulnar gutter splinting. To aid with the application of the splint, a hole can be cut out for the thumb in the stockinette, Webril and plaster (Figure 12-14).
Thumb Spica Splinting
Thumb spica splinting is used for first metacarpal injuries, ligament injuries of the thumb, navicular fractures, lunate injuries and de Quervain tenosynovitis.
Remove all jewelry from the extremity. To apply the splint, the hand is held in a neutral position with the thumb extending up. Stockinette is measured out and should be longer than the splint. The excess is trimmed away, freeing the uninjured fingers (Figure 15). Webril is applied, working distal to proximal, with three or four layers around the thumb, bony prominence of the wrist and the end of the splint. The remainder of the extremity can be wrapped in two layers. The Webril should extend down the forearm, about two-thirds of the length of the radius (Figure 16). The plaster is applied similar to an ulnar gutter splint, only encompassing the thumb (Figure 17). An elastic bandage is applied (Figure 18). The splint is formed with the thumb extended and wrist in neutral position as it dries (Figure 19). A neurovascular check should be done after splinting.
The patient should be instructed to keep the splint dry and to not remove it, and to return if increased pain, numbness, tingling or color changes occur.
The patient should be given a sling and instructed to keep the hand elevated. Sling range-of-motion instructions should be given to avoid a stiff elbow or shoulder. Have the patient remove the arm from the sling several times a day to flex, extend and pronate the elbow. The patient also should perform gentle shoulder range-of-motion exercises. Within the first day of immobilization, chondrocyte activity changes, signaling the beginning of degeneration.5The second day brings a noticeable decrease in proteoglycans, which contribute to the stiffness of cartilage. By the third day, degenerative changes are seen in chondrocytes in the areas of contact between articular surfaces, and by the fourth day, there is a marked decrease in proteoglycan content. As the tissue contracts and reorganizes, it becomes denser and, usually within a week, results in restricted range of motion.5The patient should be instructed to follow up with a primary care provider or orthopedic specialist as soon as possible, in no longer than one week.
Complications from splinting include neurovascular injuries from splints that are too tight and dermal injuries from sharp edges, pressure points or burns.6-10Several studies have shown that the risk of thermal injury is significant when the dip water temperature is too hot (greater than 50 C).
Complications also can arise from the noncompliant patient who wears the splint too long without appropriate follow-up. These complications can include infection from underlying wounds, malunion and atrophy.
The splinting methods described here are for initial immobilization. The patient should have close follow-up by the appropriate health care provider. No two fractures are alike, and splinting may have to be modified for each individual situation. Moreover, other injuries often accompany a fracture, such as foreign bodies, lacerations and other bone and tendon injuries. Following these basics should deliver a good outcome for the patient.
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2. van Onselen EBH, Karim RB, Hage JJ, Ritt MJPF. Prevalence and distribution of hand fractures. J Hand Surg Br. 2003;28(5):491-495.
3. Morgan WJ, Slowman LS. Acute hand and wrist injuries in athletes: evaluation and management. J Am Acad Orthop Surg. 2001;9(6):389-400.
4. Katzman BM, Klein DM, Mesa J, Geller J, Caligiuri DA. Immobilization of the mallet finger: effects on the extensor tendon. J Hand Surg Br. 1999;24(1):80-84.
5. Naffe A, Iype M, Easo M, et al. Appropriateness of sling immobilization to prevent lead displacement after pacemaker/implantable cardioverter-defibrillator implantation. Proc (Bayl Univ Med Cent). 2009;22(1):3-6.
6. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008;16(1):30-40.
7. Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg. 2008;16(10):586-595.
8. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. 2000;8(2):111-121.
9. Lilly SI, Messer TM. Complications after treatment of flexor tendon injuries. J Am Acad Orthop Surg. 2006;14(7):387-396.
10. Ulrich FFA. A splint for treatment of stiff fingers. J Bone Joint Surg Am. 1920:2(6);321-326.
Len McCawley is a physician assistant at the Mercy Fitzgerald Hospital emergency department in Darby, Pa. He indicates no relationships to disclose related to the contents of this article.