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Phalangeal Fracture Fixation

72 citationsUpdated Oct 2026
Illustration: hand

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Internal fixation of metacarpal and phalangeal fractures is a reliable method for fractures with significant displacement, rotation, angulation, and/or instability [11]. The primary goals of this intervention are stable anatomic fracture restoration and early functional recovery [6]. While intramedullary hand nails may be beneficial with acceptable joint cartilage damage [30], screw fixation is suggested to achieve patient satisfaction and optimal functional recovery specifically for closed, isolated proximal phalanx fractures of the long fingers [1]. For unstable proximal and middle phalangeal fractures, fixation using a titanium plate and screws through a midlateral approach is a reliable and safe method associated with higher total active motion and fewer complications [26].

Various fixation modalities offer distinct advantages depending on fracture location and stability. Evidence favors the lateral plating approach for proximal phalanx fractures [36], although no differences in outcome were observed between dorsal and lateral plate fixation [2]. Dorsal plating with unicortical angular stable screws is suitable for proximal phalangeal fractures [20], and the low-profile titanium plate system is highly effective in maintaining anatomic reduction for comminuted metacarpal and phalangeal fractures [15]. Miniature plates and screws are a possible choice for low-severity metacarpal and phalangeal fractures [4]. Intramedullary screw fixation is safe and effective for extra-articular proximal [9, 29] and middle phalangeal fractures [10], providing stable fixation to allow early motion. Flexible intramedullary rodding provides excellent results with a low complication rate for specific proximal phalangeal fractures [19].

Percutaneous techniques and alternative rigid fixation methods are also viable options. Closed reduction and percutaneous Kirschner-wire fixation by a joint-sparing approach yields good functional results with minimal complications in proximal phalangeal neck fractures [5], and percutaneous pinning is an adequate method for unstable proximal phalanx fractures [14]. A specific technique uses flexion of the interphalangeal joints during K-wire insertion to maintain reduction for acute, unstable extra-articular middle phalangeal neck fractures [27]. A minimally invasive technique for screw fixation combines the advantages of percutaneous K-wire stabilisation with internal rigid fixation [23]. Screw fixation of distal phalanx fractures resulted in greater distal interphalangeal joint motion compared with K-wire fixation but required removal in half of cases [16]. Intramedullary hand screw fixation could be considered as current practice for extra-articular unstable fractures of metacarpals and phalanges, including complex cases [7]. Rigid internal fixation of basilar metaphyseal proximal phalangeal fractures by cancellous bone grafting alone is feasible and produces rewarding results [28]. The use of proximally locked nails may safely extend indications to rotationally and longitudinally unstable fractures and minimizes the need for postoperative splinting in metacarpal fractures [24].

Anatomy & Pathophysiology

Bony Anatomy

The hand skeleton comprises 27 bones, 19 of which are long bones [52]. These bones are organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [52]. The proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [52]. Epiphyseal plates are located at the proximal ends of the phalanges [52]. A longitudinal groove runs the length of the proximal phalangeal shaft [107].

Soft Tissue Anatomy

Extrinsic extensor tendons are stabilized over the metacarpophalangeal joint by attachment to sagittal band fibers, which insert onto the volar proximal phalanx and the lateral borders of the volar plate [51]. The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [51]. The flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [79]. The A2 and A4 pulleys are situated over the middle portions of the proximal and middle phalanges, respectively, and are the most essential structures in maintaining the mechanical advantage of the flexor tendons [79].

Intrinsic muscle positioning follows a specific pattern: dorsal interossei lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers, while volar interossei lie to the ulnar side of the index finger and the radial side of the ring and little fingers [72]. The superficial head of the dorsal interosseous muscles inserts onto the lateral tubercle of the base of the proximal phalanx [72]. The deep head forms a lateral band at the level of the metacarpophalangeal joint [72]. Transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger at the level of the middle of the proximal phalanx [72]. Oblique fibers from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx [72].

Dorsal skin has loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [81]. In the proximal part of the first phalanx, skin fixation occurs in a straight line in the plane of the commissural crest [81]. More distally on the proximal phalanx, the adhesion band lies just posterior to the palmar collateral neurovascular bundle on the lateral side [81]. The dorsal skin lengthens by an average of 3 cm as the middle finger moves from extension to full flexion [81].

Pathophysiology

Fractures of the proximal phalangeal shaft typically exhibit apex palmar angulation, with the fracture gap wider volarly and compressed dorsally [22]. This deformity results from intrinsic muscles flexing the proximal fragment, while the distal fragment is extended by the attachment of the central slip to the dorsal lip of the middle phalanx [22]. The axis of rotation for these fractures lies on the fibro-osseous border of the flexor tendon sheath [22]. The moment arm from this rotational axis to the extensor tendon is greater than that to the flexor tendon [22].

Fracture hematoma permeates the zone of injury, inciting a proliferative fibroblastic response of surrounding collagenous structures [22]. Scar tissue tends to involve all structures within this zone, producing adherence between bone and adjacent tendons, joint capsule, and ligaments [22]. Adhesions formed between the extensor mechanism and the fracture may result in loss of extensor glide [22]. Persistent skeletal deformity may contribute to PIP joint extensor lag [22].

The immediate vicinity of the flexor tendon to the volar cortex of the proximal phalanx gives low tolerance to a protruding screw [66]. Dorsally placed bicortical screws could protrude into the longitudinal groove of the phalangeal shaft unnoticed on intraoperative imaging, potentially causing impingement on the flexor tendon [107].

Classification

Chow et al.: Chow et al. (1991) classified extra-articular fractures of the proximal phalanx according to concurrent soft tissue injury [32]. Displaced unstable transverse fractures of the shaft of the proximal phalanx are described as "troublesome shaft fractures" and the "no man's land" of hand fractures [32]. A rate of 25% of poor outcome has been observed in Chow's type I fractures despite favourable soft tissue conditions [32].

AO: The AO classification was used to categorize displaced proximal phalangeal fractures into types A (extra-articular/monofracture diaphyse), B (partial joint/diaphyseal wedge), and C (complete joint/diaphyseal complex) [110]. AO type B3.1 phalangeal fractures are a specific classification category for which K-wire combined with screw fixation has been evaluated [58].

Other Considerations: Proximal phalangeal fractures are commonly managed based on their stability [42].

Clinical Presentation

Proximal phalangeal fractures constitute 7% of all hand fractures and 0.3% of all attendances in a two-year Accident and Emergency department review [33]. In a cohort of 48 patients, 52% of these fractures were located in the little finger, 40% were intra-articular, and 46% involved the dominant hand [21]. Displaced unstable transverse shaft fractures are common in industrial workers, typically resulting from heavy objects falling on the hand [32]. These injuries are described as "troublesome shaft fractures" and the "no man's land" of hand fractures [32].

The axis of rotation for proximal phalangeal fractures lies on the fibro-osseous border of the flexor tendon sheath [22]. Fracture hematoma permeates the zone of injury and incites a proliferative fibroblastic response proportionate to injury severity [22]. Simple fractures caused by low-energy injuries may be complicated by permanent stiffness due to soft tissue adhesion formation [22]. Persistent skeletal deformity and soft tissue adhesions are two major causes of PIP joint extensor lag following proximal phalangeal fractures [22].

A rate of 25% of poor outcome has been observed in Chow's type I transverse fractures of the proximal phalanx despite favourable soft tissue conditions [32]. Phalangeal fractures, older age, and associated soft-tissue injuries are significant risk factors for reduced range of finger motion in comminuted periarticular fractures treated with titanium plates [37]. Pain in the post-operative week predicts pain and hand use twelve weeks after proximal phalangeal fracture fixation [21]. Patients who commence active finger exercise early following proximal phalanx fracture surgical fixation may achieve greater total active range of motion at 6 weeks post-operatively than if active exercise is delayed [31].

Investigations

Phalangeal fractures of the hand represent the second most common upper-extremity fracture in the United States, with a fracture incidence of 130/100,000 persons [45]. A careful physical examination is essential to direct care and future testing if indicated for the injured or dysfunctional hand and wrist [50]. While diagnostic tests such as imaging and serum laboratory studies are useful in determining the scope of possible pathologic processes, they can be expensive, time consuming, and often nonspecific [50]. Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit, whether real or imagined [50]. Consequently, the task of the astute clinician is to combine the patient history with a careful physical examination to pinpoint or at least narrow the scope of possible pathologic processes [50].

Other Considerations: The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [52]. This skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [52]. The base of each metacarpal articulates with the distal row of the carpus [52]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [52]. The thumb metacarpal is the shortest, and the index metacarpal is by far the longest [52]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [52]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [52].

Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [51]. Distal interphalangeal joint extension is achieved through the conjoined lateral bands that are composed of tendinous slips from the extrinsic and intrinsic tendons [51]. The sagittal bands normally keep the extrinsic extensor as far as possible away from the center of rotation of the metacarpophalangeal joint, thereby giving it the greatest mechanical efficiency [51]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [51]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [51]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [51].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy regimens, NSAIDs, or injections for phalangeal fractures.

Operative

Indications: Screw fixation is indicated for oblique and spiral fractures of the proximal phalanx, certain fractures with large single articular fragments involving the proximal interphalangeal joint, and appropriate Bennett's fractures [60]. Intramedullary headless screw fixation is considered current practice for extra-articular unstable fractures of metacarpals and phalanges, including complex cases [7]. Open fractures of proximal and middle phalangeal shafts with both palmar and dorsal wounds require delayed fixation of K-wires, otherwise stabilized immediately after injury [48].

Surgical Approach / Technique: Closed reduction and percutaneous Kirschner-wire fixation by a joint-sparing approach yields good functional results with no or minimal complications in proximal phalangeal neck fractures [5]. Closed reduction and percutaneous pinning using various techniques is an adequate method for unstable proximal phalanx fractures [14]. This procedure requires two surgeons, with one reducing the fracture via longitudinal traction while the other introduces Kirschner wires percutaneously [63]. Kirschner wires are left protruding through the skin and bent at a right angle or into a small loop to prevent migration and facilitate removal [63]. For middle phalangeal neck fractures, percutaneous pinning uses flexion of the interphalangeal joints during K-wire insertion to maintain fracture reduction and improve fixation for acute, unstable extra-articular fractures [27]. Intramedullary fixation through a volar extra-tendon sheath approach may be an alternative for proximal phalangeal shaft fractures due to its less invasive nature, although it does not offer anatomical reduction [12]. Antegrade intramedullary screw fixation of proximal phalangeal fractures can be performed using percutaneous approaches without significant disruption to the extensor mechanism [34]. Fixation of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral approach is a reliable and safe method associated with higher total active motion (TAM) and fewer complications [26]. Dorsal plating using a 1.5-mm modular hand plate is a viable option for rigid fixation of intra-articular middle phalangeal base fractures with volar instability [49]. A simple phalangeal external fixator using Kirschner wires and locking balls may be a useful tool for open and/or highly comminuted fractures and fracture-dislocations of the proximal and middle phalanges [104].

Implant Selection: Screw fixation is suggested to achieve patient satisfaction and optimal functional recovery for closed, isolated proximal phalangeal fractures of the long fingers [1]. Excellent outcomes were achieved following open reduction and internal fixation (ORIF) of proximal phalangeal fractures, providing a benchmark for recovery [3]. Intramedullary screw (IMS) fixation for proximal phalangeal fractures provides good functional outcomes and a low complication rate [8]. Intramedullary screw fixation of proximal phalangeal fractures is safe and provides stable fixation to allow early motion [9]. Intramedullary screw fixation is a viable option for the treatment of extra-articular middle phalangeal fractures [10]. Intramedullary compression screw (IMCS) fixation is a reliable technique for the surgical management of transverse and short oblique metacarpal, proximal, and middle phalangeal fractures [25]. Intramedullary screws for unstable metacarpal and phalangeal fractures demonstrate superior biomechanical strength and early active range of motion compared to other methods [62]. Phalangeal fractures are treated with one or two 2-mm screws, inserted antegrade or retrograde [62]. Intramedullary placement of implants avoids hardware prominence and extensive soft-tissue stripping, which can impact tendon gliding and postoperative range of motion [62]. Phalanx fracture fixation with intramedullary hand nails has acceptable joint cartilage damage based on study data [30]. Reverse instrumentation for headless compression screw fixation of basal proximal phalangeal fractures resulted in full range of motion at 6-week postoperative follow-up with no complications in a case illustration [40].

Alignment / Balancing Strategy: No differences in outcome were observed between dorsal and lateral plate fixation for finger proximal phalangeal fractures [2]. A systematic review and meta-analysis demonstrates evidence favoring the lateral plating approach when fixing proximal phalanx fractures [36]. No considerable biomechanical advantage of using a conventional 1.5 mm dorsal non-locking plate was identified over the novel 1.3 mm lateral locking plate in the treatment of proximal phalangeal fractures [55]. Closer distance between the plate edge and joint line is associated with a more limited range of finger motion when using a locking plate system for unstable metacarpal and phalangeal fractures [17]. Both unicortical and bicortical locking screws provide sufficient stability to facilitate early motion without risk of clinically relevant displacement during plate fixation of midshaft proximal phalangeal fractures [18]. The use of proximally locked nails may safely extend indications to rotationally and longitudinally unstable fractures and minimizes the need for postoperative splinting in metacarpal fractures [24].

Other Considerations: Surgical treatment of proximal phalangeal fractures requires a second “planned injury,” superimposing further soft tissue injury and increasing the risk of soft tissue adhesions [22]. Two major causes of PIP joint extensor lag following proximal phalangeal fractures are soft tissue adhesions and persistent skeletal deformity [22]. The simple phalangeal external fixator allows for early active motion and can be removed in the office [104]. By Week 6, there were no significant between-group differences in improvement for active proximal interphalangeal joint extension, total active finger range of motion, strength, pain, difficulty with specific hand activity, or difficulty with usual hand activity between two types of exercise after proximal phalangeal fracture fixation [43]. The authors caution against prescribing any single method for fixing a particular type of fracture, recommending an individualised management strategy that considers fracture configuration, surgeon and patient preferences, and likely patient compliance [102].

Complications

General Complication Rates: Surgical treatment of digital fractures carries a significant complication burden. Even with pin fixation alone, overall complications occur in 18% of cases, comprising 7% infection, 5% pin loosening, and 4% nonunion [100]. In a series of 37 phalangeal fractures, 92% experienced one or more complications, including extensor lag in 60% and fixed contracture in 38% [100]. Good or excellent results were achieved in 59% to 76% of fingers in a prospective study of 924 digital fractures [100].

Stiffness and Range of Motion: Postoperative finger stiffness occurred in 43% of fractures treated with titanium plates and/or screws [57]. Complication rates after plate fixation have been reported at 52% and 82%, primarily driven by excessive stiffness defined as total active motion of less than 180 degrees [100]. Closer distance between the plate edge and joint line is associated with more limited range of finger motion [17]. Phalangeal fractures, older age, and associated soft-tissue injuries are significant risk factors for reduced range of motion [37]. Patients who commence active finger exercise early following proximal phalanx fracture surgical fixation may achieve greater total active ROM at 6 weeks post-operatively than if active exercise is delayed [31]. Both techniques of percutaneous pinning for proximal phalangeal base fractures resulted in permanent reduction in range of motion at the MCP and PIP joints [47]. In a comparison of K-wire and lag screw fixation for long oblique proximal phalanx fractures, the mean loss of extension of the proximal interphalangeal joint was 8° (range 0-30) in the Kirschner wire group and 27° (range 0-60) in the lag screw group [106].

Infection and Wound Complications: There was no significant difference in postoperative infection rates between buried and exposed K-wires [87]. Open fractures with both palmar and dorsal wounds should be treated with delayed fixation of K-wires otherwise stabilized immediately after injury [48]. A patient with Kirschner wire fixation failure experienced a wound infection following a release of the palmar plate, resulting in a fixed flexion deformity of 40° at the proximal interphalangeal joint [106]. Traumatic avulsion of the finger nail in skeletally immature patients should be recognized as an open fracture to prevent complications such as infection and premature epiphyseal closure [119].

Hardware and Fixation Failures: Unplanned reoperation was more prevalent after plate fixation compared to other fixation methods for proximal phalanx fractures [117]. Screw fixation of distal phalanx fractures was associated with a 52% incidence of symptomatic hardware necessitating operative removal [39]. In a study of long oblique proximal phalanx fractures, one Kirschner wire fixation failed after 3 weeks with redisplacement of the fracture [106]. In the same study, one lag screw fixation failed after 6 weeks and an angular deformity developed [106]. Additionally, one fracture shortened following removal of the Kirschner wires at 4 weeks [106]. Residual abduction or adduction angulation was observed in four patients in the Kirschner wire group (maximum 41°) and five patients in the lag screw group (maximum 141°) for long oblique proximal phalanx fractures [106]. Patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates [86].

Soft Tissue and Tendon Complications: In the proximal phalanx, the immediate vicinity of the flexor tendon to the volar corticalis gives low tolerance to a protruding screw [66]. Potential complications of open reduction and internal fixation of proximal phalangeal fractures include iatrogenic neuroma of the dorsal oblique nerve branches and detachment of the flexor sheath origin, leading to pulley insufficiency (especially the A2 pulley) [100]. Suture anchors should be used with caution in the little finger and patients forewarned about potential complications [44].

Specific Technique Outcomes: Intramedullary compression screw fixation for proximal phalangeal fractures is associated with a low complication rate [8]. Dual antegrade intramedullary headless screw fixation of proximal phalanx fractures resulted in no complications with follow-up of at least 1 year [65]. Fixation of unstable proximal and middle phalangeal fractures using a titanium plate and screws is associated with fewer complications compared to Kirschner wires [26].

Recovery

Light activity (weeks): The evidence does not specify a defined week range for light activity such as desk work or driving. However, fracture bracing for proximal phalanx fractures is successful in that patients have greater range of motion once the fracture is healed, reducing the length of later rehabilitation [93]. Intramedullary percutaneous fixation of extra-articular proximal and middle phalangeal fractures allows immediate mobilization of fingers, concurrent stabilization with progressive healing, and prevents complications such as stiffness and extensor lag [61].

Full activity (months): The evidence does not specify a defined month range for full activity or manual work. Bridge plating for first proximal phalanx intra-articular base fractures may maintain alignment and articular congruity while permitting earlier return to activities of daily living [108]. Dorsal transosseous reduction and locking plate fixation for articular depressed middle phalangeal base fractures provides satisfactory restoration of articular congruence and enables early joint mobilization [94].

Complete recovery / outcome plateau (months): The evidence does not specify a defined month range for complete recovery or outcome plateau.

Rehabilitation protocol: Stiffness and extensor lag at the proximal or distal interphalangeal joint almost always occur irrespective of using an open or closed technique of fixation for proximal and middle phalangeal fractures if early mobilization is not allowed [61]. Closed techniques with K-wires require immobilization, while open techniques are heralded by adhesions of the extensor mechanism resulting in stiffness at the proximal interphalangeal joint, extensor lag, and limited range of motion [61]. Fracture bracing for proximal phalanx fractures has been found to be successful in that patients have greater range of motion once the fracture is healed, reducing the length of later rehabilitation [93]. Intramedullary percutaneous fixation of extra-articular proximal and middle phalangeal fractures allows immediate mobilization of fingers, concurrent stabilization with progressive healing, and prevents complications such as stiffness and extensor lag [61].

Functional milestones: Excellent outcomes were achieved in a prospective longitudinal study, providing a benchmark for recovery after open reduction and internal fixation of proximal phalangeal fractures [3]. Miniature plates and screws yielded very favourable results, suggesting they are a possible choice for low-severity metacarpal and phalangeal fractures [4]. Intramedullary headless screw fixation (IHSF) could be considered as current practice for treating extra-articular unstable fractures of metacarpals and phalanges, including complex cases, based on a multicentre study with long-term follow-up [7]. Intramedullary screw (IMS) fixation for proximal phalangeal fractures is associated with good functional outcomes and a low complication rate [8]. A low-profile titanium plate system was highly effective in maintaining anatomic reduction for comminuted metacarpal and phalangeal fractures despite technical demands [15]. Screw fixation of distal phalanx fractures resulted in greater distal interphalangeal joint motion compared with K-wire fixation [16]. Clinical outcomes for unstable metacarpal and phalangeal fractures treated with a locking plate system approached an acceptable level at final follow-up [17].

Other Considerations: Closer distance between the plate edge and joint line is associated with a more limited range of finger motion in unstable metacarpal and phalangeal fractures treated with a locking plate system [17]. Screw fixation of distal phalanx fractures required removal in half of cases [16]. Phalangeal fractures, older age, and associated soft-tissue injuries were significant risk factors for reduced range of finger motion in comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate [37]. Soft tissue adhesions and persistent skeletal deformity are two major causes of PIP joint extensor lag following proximal phalangeal fractures [22]. Scar tissue from fracture hematoma tends to involve all structures within the zone of injury, producing adherence between bone and adjacent tendons, joint capsule, and ligaments, especially when tendons remain dormant during healing [22]. The intrinsic muscles flex the proximal fragment, whereas the distal fragment is extended by the attachment of the central slip to the dorsal lip of the middle phalanx in proximal phalangeal shaft fractures [22]. Bridge plating for thumb fractures avoids the risk of pin-track infections associated with external fixation [108].

Key Evidence

  • [L4] The authors suggest using screw fixation to achieve patient satisfaction and optimal functional recovery of closed, isolated proximal phalanx fractures of the long fingers. [1] (10.1016/j.hansur.2016.08.009)
  • [L3] No differences in the outcome of finger proximal phalangeal fractures treated by dorsal and lateral plate fixation were observed. [2] (10.1007/s00402-017-2650-x)
  • [L3] Excellent outcomes were achieved, providing a benchmark for recovery after ORIF of proximal phalangeal fractures. [3] (10.1177/1753193416670591)
  • [Paper] These very favourable results suggest that miniature plates and screws are a possible choice in the treatment of low-severity metacarpal and phalangeal fractures. [4] (10.1007/s00402-004-0745-7)
  • [L2] Closed reduction and percutaneous Kirschner-wire fixation by a joint sparing approach will yield good functional results with no or minimal complications in proximal phalangeal neck fractures. [5] (10.1177/1753193419894143)
  • [L5] Stable anatomic fracture restoration and early functional recovery are the goals of internal fixation of hand fractures. [6] (10.1016/j.hcl.2009.05.005)
  • [L4] On the basis of the results of this multicentre study with a long-term follow-up, we believe that IHSF could be considered as the current practice to treat extra-articular unstable fractures of metacarpals and phalanges, not only in case of single fractures but also in complex cases. [7] (10.1177/1753193420980324)
  • [L4] This updated systematic review finds good functional outcomes and a low complication rate following the use of IMS fixation for proximal phalangeal fractures. [8] (10.1177/15589447251329597)
  • [L4] Intramedullary screw fixation of proximal phalangeal fractures is safe, providing stable fixation to allow early motion. [9] (10.1177/1558944720928503)
  • [L4] Intramedullary screw fixation is a viable option in the treatment of extra-articular middle phalangeal fractures. [10] (10.1016/j.jhsa.2023.12.011)
  • [L4] Internal fixation of metacarpal and phalangeal fractures is a reliable method for fractures with significant displacement, rotation, angulation and/or instability. [11] (10.1016/0020-1383(93)90283-c)
  • [L4] Intramedullary fixation through a volar extra-tendon sheath approach may be an alternative for treatments of the proximal phalangeal shaft fractures because of its less invasive nature, although it does not offer anatomical reduction. [12] (10.1142/s0218810411005230)
  • [L5] Closed reduction and percutaneous pinning using any of the presented techniques is an adequate method of treatment for unstable proximal phalanx fractures. [14] (10.1177/15589447211017224)
  • [L4] Despite the technical demands of plating for comminuted metacarpal and phalangeal fractures, the low-profile titanium plate system was highly effective in maintaining anatomic reduction. [15] (10.1016/j.jhsa.2008.01.040)
  • [L3] Screw fixation of distal phalanx fractures resulted in greater distal interphalangeal joint motion compared with K-wire fixation but required removal in half of cases. [16] (10.1016/j.jhsa.2015.06.125)
  • [L2] Closer distance between the plate edge and joint line is associated with a more limited range of finger motion, and clinical outcomes approached an acceptable level at final follow-up. [17] (10.1177/1753193419899332)
  • [L5] Both unicortical and bicortical locking screws provide sufficient stability to facilitate early motion without risk of clinically relevant displacement during plate fixation of midshaft proximal phalangeal fractures. [18] (10.1016/j.jhsa.2025.03.009)
  • [L4] Flexible intramedullary rodding of specific proximal phalangeal fractures provides excellent results with a low complication rate. [19] (10.1016/s0363-5023(05)80436-8)
  • [L4] Dorsal plating with unicortical angular stable screws is suitable for proximal phalangeal fractures. [20] (10.1177/1558944716660555db)
  • [L3] [21] (10.1142/s2424835519500607)
  • [Paper] [22] (10.1016/s0894-1130(03)80008-x)
  • [L5] The authors describe a minimally invasive technique for screw fixation of phalangeal finger fractures that combines the advantages of percutaneous K-wire stabilisation with internal rigid fixation. [23] (10.1016/j.injury.2020.04.020)
  • [L4] The use of proximally locked nails may safely extend the indications to rotationally and longitudinally unstable fractures and minimizes the need for postoperative splinting in metacarpal fractures. [24] (10.1016/j.hcl.2006.02.017)
  • [L4] IMCS fixation is a reliable technique for the surgical management of transverse and short oblique metacarpal, proximal and middle phalangeal fractures. [25] (10.1302/2058-5241.5.190068)
  • [L2] Fixation of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral approach is a reliable and safe method for most fracture types and is associated with higher TAM and fewer complications. [26] (10.1016/j.jhsa.2019.01.015)
  • [L4] The presented technique uses flexion of the interphalangeal joints during K-wire insertion to maintain fracture reduction and improve fixation for acute, unstable extra-articular middle phalangeal neck fractures. [27] (10.1016/j.jhsa.2012.06.011)
  • [L4] Rigid internal fixation of basilar metaphyseal proximal phalangeal fractures by cancellous bone grafting alone is feasible and produces rewarding results. [28] (10.1054/jhsb.2001.0641)
  • [L4] This study concurs with the prior literature that intramedullary screw fixation is a safe and effective method of stabilizing extra-articular proximal phalangeal fractures in the short to medium term. [29] (10.1177/15589447241235339)
  • [L5] Phalanx fracture fixation with intramedullary hand nails may be beneficial as it has acceptable joint cartilage damage based on study data. [30] (10.1016/j.jhsg.2025.100928)
  • [L4] Patients who commence active finger exercise early following proximal phalanx fracture surgical fixation may achieve greater total active ROM at 6 weeks post-operatively than if active exercise is delayed. [31] (10.1177/1758998316679386)
  • [L4] [32] (10.1177/1753193411405943)
  • [L4] [33] (10.1016/0266-7681(92)90123-j)
  • [Paper] Antegrade intramedullary screw fixation of proximal phalangeal fractures can be performed using percutaneous approaches without significant disruption to the extensor mechanism. [34] (10.1177/15589447251339502)
  • [L1] This study demonstrates evidence favoring the lateral plating approach when fixing proximal phalanx fractures. [36] (10.1177/15589447251378679)
  • [L3] Phalangeal fractures, older age, and associated soft-tissue injuries were significant risk factors for reduced range of finger motion. [37] (10.1016/j.injury.2012.02.011)
  • [Commentary] [39] (10.1016/j.jhsa.2015.08.021)
  • [L4] [40] (10.1016/j.jhsa.2022.12.012)
  • [L5] [42] (10.1177/17531934251316495)
  • [L1] By Week 6, there were no significant between-group differences in improvement for active proximal interphalangeal joint extension, total active finger range of motion, strength, pain, difficulty with specific hand activity, or difficulty with usual hand activity. [43] (10.1016/j.jphys.2015.11.006)
  • [L5] Suture anchors should be used with caution in the little finger and patients forewarned about potential complications. [44] (10.1177/1753193411419595)
  • [L5] [45] (10.1016/j.jhsg.2026.101064)
  • [L3] Both techniques resulted in permanent reduction in range of motion at the MCP and PIP joints. [47] (10.1016/s0363-5023(12)60053-7)
  • [L3] Open fractures with both palmar and dorsal wounds should be treated with delayed fixation of K-wires otherwise stabilized immediately after injury. [48] (10.1038/s41598-017-11918-2)
  • [L4] Dorsal plating using a 1.5-mm modular hand plate is a viable option for rigid fixation of intra-articular middle phalangeal base fractures with volar instability. [49] (10.1177/1558944718777868)
  • [L5] No considerable biomechanical advantage of using a conventional 1.5 mm dorsal non-locking plate was identified over the novel 1.3 mm lateral locking plate in the treatment of proximal phalanx fractures. [55] (10.1016/j.clinbiomech.2015.03.019)
  • [L2] Postoperative finger stiffness occurred in 43% of fractures. [57] (10.1016/j.jhsa.2014.06.107)
  • [L3] Compared with simple K-wire fixation, K-wire combined with screw in the treatment of AO type B3.1 phalangeal fractures is a safer and reliable surgical method. [58] (10.1186/s12891-023-06731-0)
  • [L4] Screw fixation is indicated for a small percentage of hand fractures, specifically oblique and spiral fractures of the proximal phalanx, certain fractures with large single articular fragments involving the proximal interphalangeal joint, and appropriate Bennett's fractures. [60] (10.2106/00004623-197658040-00010)
  • [L4] [61] (10.1097/bth.0000000000000188)
  • [Paper] [62] (10.2106/jbjs.st.23.00032)
  • [L4] [63] (10.2106/00004623-197355080-00009)
  • [L4] Dual antegrade IMHS fixation of proximal phalanx fractures resulted in excellent postoperative motion, near-normal grip strength, positive self-reported patient outcomes, and no complications with follow-up of at least 1 year. [65] (10.1177/1558944717750919)
  • [L4] In the proximal phalanx, the immediate vicinity of the flexor tendon to the volar corticalis gives low tolerance to a protruding screw. [66] (10.1016/s0363-5023(03)80400-8)
  • [L3] This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. [86] (10.1177/15589447241232009)
  • [L3] There was no significant difference in postoperative infection rates between buried and exposed K-wires. [87] (10.1016/j.injury.2018.02.027)
  • [L5] We have found this treatment approach to be successful in that patients have greater range of motion once the fracture is healed, therefore reducing the length of later rehabilitation. [93] (10.1016/s0894-1130(96)80050-0)
  • [L4] This technique provides satisfactory restoration of articular congruence and enables the early joint mobilization of articular depression-type fractures of the base of the middle phalanx. [94] (10.1007/s00402-018-3074-y)
  • [L5] [100] (10.1097/bth.0b013e318174dc0a)
  • [L5] The authors caution against prescribing any single method for fixing a particular type of fracture, recommending an individualised management strategy that considers fracture configuration, surgeon and patient preferences, and likely patient compliance. [102] (10.1177/1753193411433386)
  • [L4] [104] (10.1016/j.jhsa.2016.04.017)
  • [L1] [106] (10.1054/jhsb.2002.0807)
  • [L5] A longitudinal groove runs the length of the phalangeal shaft, and dorsally placed bicortical screws could protrude into this groove unnoticed on intraoperative imaging, potentially causing impingement on the flexor tendon. [107] (10.1016/j.jhsa.2016.12.009)
  • [L4] Bridge plating may be an alternative to external fixation for certain thumb fractures, with the potential to maintain alignment and articular congruity while permitting earlier return to activities of daily living and avoiding the risk of pin-track infections. [108] (10.1016/j.jhsg.2022.09.003)
  • [L4] [110] (10.1053/jhsu.1999.1254)
  • [L4] Overall patient-reported outcome measure scores were similar across fixation methods, and unplanned reoperation was more prevalent after plate fixation. [117] (10.1016/j.jhsa.2019.08.010)
  • [L4] Traumatic avulsion of the finger nail in skeletally immature patients should be recognized as an open fracture to prevent complications such as infection and premature epiphyseal closure. [119] (10.2106/00004623-197860050-00027)

See Also

References

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a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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