Surgical Anatomy. — The phalanges are practically subcutaneous throughout and fractures of these bones are, as a rule, detected without difficulty. The fleshy pads on the palmar aspect of the fingers are comparatively thick, and palpation on this side of the digit is less satisfactory than elsewhere. The quadrilateral expanded bases may be palpated without difficulty. The internal structure of the phalanges is similar to that found in other long bones. The extremities are composed of cancellous tissue covered by a thin layer of compact bone, while the shafts consist of tubes of heavy compact tissue. Accordingly fractures occurring in the extremities are more prone to show comminution and crushing of cancellous tissues, while breaks through the shafts are usually clean cut and never impacted.<Callout type="important" title="Important">Prolonged immobilization following traumatic inflammation can lead to adhesions between tendons and their sheaths, limiting motion after recovery.</Callout> The dorsal aspect of each finger, from the head of the metacarpal to the base of the terminal phalanx, is in contact with the extensor tendon. The anterior aspect of each digit is in relation with the flexor tendons. The tendons of the flexor sublimis digitorum are inserted into the sides of each middle phalanx, while the tendons of the flexor profundus digitorum are inserted into the bases of the terminal phalanges. These tendons and the synovial sheaths enclosing them are of considerable importance in the treatment of fractures of the fingers.<Callout type="gear" title="Gear">Plaster splints, adhesive strips, and cotton padding are essential for immobilizing injured fingers.</Callout> Epiphyseal separations are rare in the fingers though they are occasionally seen. Each phalanx is ossified by two centers, one for the base and one for the head and shaft. The bases of the proximal row of phalanges begin to ossify during the third or fourth year and join the shafts at about the eighteenth year. The shafts of all the phalanges show signs of ossification soon after birth.<Callout type="risk" title="Risk">Severe crushes can lead to necrosis and non-union, potentially requiring amputation.</Callout> The prominences of the knuckles do not correspond to the planes of the joint but are formed by the heads of the bones above the articulation. The digital vessels and nerves run on either side of, and a little ventral to, the lateral borders of the phalanges.<Callout type="tip" title="Tip">Fractures near the end of the phalanx can be difficult to recognize due to joint proximity.</Callout> The use to which the hands are put in different trades and various types of labor exposes the fingers to all kinds of direct violence. This is particularly true of those working about machinery. The fact that the phalanges are subcutaneous results in a high proportion of compound fractures and luxations, even though the skin covering these parts is heavy and strong. Fractures of the fingers, especially those produced by machinery, are often accompanied by severe and extensive laceration and bruising of the overlying soft tissues.<Callout type="beginner" title="Beginner">Finger injuries from machinery can be overlooked due to initial lack of symptoms.</Callout> Symptoms. — Local pain, loss of function and swelling of the injured finger are almost invariably present. Crepitus and abnormal mobility can usually be elicited without difficulty. When the fracture is near the end of the phalanx the point of preternatural mobility may be difficult to recognize because of the proximity of the joint.<Callout type="warning" title="Warning">Failure to use X-rays for diagnosis in cases of doubt can lead to misdiagnosis and improper treatment.</Callout> Treatment. — The proper treatment of fractures of the fingers is of greater importance than would at first appear since there is only a small proportion of men who do not depend, at least partially, on their hands for a livelihood. A crippled hand often means impaired earning capacity.<Callout type="important" title="Important">Correct deformity as soon as possible and immobilize the finger.</Callout> When there is deformity it should be corrected at the earliest possible moment and the finger immobilized. In fractures of the phalanges it has been customary to immobilize the injured finger in a position of complete extension. A position of slight flexion, however, will be found much more comfortable since the flexor and extensor tendons more nearly balance each other in this attitude.<Callout type="gear" title="Gear">Use straight palmar splints with padding for comfort.</Callout> The most perfect splint is made with plaster of Paris and gauze or crinoline. This form of splint fits the parts perfectly because it is moulded to them and the finger may be placed in any degree of flexion according to the needs of the case.<Callout type="risk" title="Risk">Strangulation can occur if dressings are too tightly placed.</Callout> When the fracture is compound anteriorly the splint may be placed on the dorsal aspect of the hand and will hold the parts securely. Compound fractures should be treated according to the principles laid down under the heading of 'Treatment of Compound Fractures and Luxations' on page 789. Ethereal antiseptic soap will be found of considerable advantage in the removal of dirt and grease from the hands of mechanics and machinists preparatory to washing the wound with salt solution.<Callout type="tip" title="Tip">Use ethereal antiseptic soap for cleaning wounds.</Callout> Operative Treatment. — Operation is rarely indicated in fractures of the fingers except in compound cases. The wound should be treated according to the principles set forth on page 789. Lacerated tissues should be trimmed away and the wound thoroughly irrigated before the edges are approximated. If the fracture is produced by some cutting instrument and the tendons divided they should be repaired before the wound is closed. In severe crushes of the fingers amputation may be necessary.<Callout type="important" title="Important">Begin guarded passive motion after 10 days to prevent adhesions.</Callout> After-Treatment. — During the after-treatment the finger should be carefully watched to keep the dressings properly adjusted and to prevent recurrence of deformity. If the trauma accompanying the fracture has been great it may be best to postpone the application of splints until the swelling has subsided. During this time the finger is immobilized by surrounding the digit with cotton and bandaging the adjoining fingers to it. The ice cap will tend to control the traumatic reaction. Fixation should be maintained for a period of three weeks in uncomplicated cases, but guarded passive motion begun at the end of ten days will be of the greatest advantage in preventing adhesions within the joints and between the tendons and their sheaths.<Callout type="warning" title="Warning">Necrosis can lead to non-union if not treated promptly.</Callout> In compound cases the greatest care should be exercised to prevent infection and suppuration of the wound following the initial treatment. If infection becomes established necrosis of bone and non-union are likely to follow. If necrotic bone is present it should be removed as soon as possible and an attempt made to convert the suppurating sinus into a healthy wound. If union is not present at the end of four or five weeks it is probable that it will never occur especially without surgical intervention. Under these circumstances it may be best to amputate.<Callout type="important" title="Important">Amputation may be necessary in severe crushes.</Callout> Prognosis. — The outlook in fractures of the fingers depends entirely on the severity of the injury. In simple cases recovery should be complete while in severe crushes it may be impossible to avoid amputation, to say nothing of obtaining union in the fractured phalanx. The accompanying injury sustained by the soft tissues is a most important element.
Key Takeaways
- Proper diagnosis and treatment are crucial for finger fracture recovery.
- Immobilization of injured fingers should be done carefully to prevent complications.
- X-rays can help in diagnosing complex fractures.
Practical Tips
- Always use appropriate splinting techniques to ensure comfort and proper healing.
- Regularly check the dressing to avoid recurrence of deformity during recovery.
- Use ethereal antiseptic soap for cleaning wounds to prevent infection.
Warnings & Risks
- Failure to treat severe crushes can lead to necrosis and non-union, potentially requiring amputation.
- Incorrect immobilization techniques can result in adhesions and limited mobility after healing.
- Ignoring the need for X-rays in complex cases may lead to misdiagnosis.
Modern Application
While the specific techniques described in this chapter are historical, the principles of proper diagnosis, treatment, and prevention of complications remain relevant. Modern survival preparedness emphasizes the importance of these practices, especially in environments where medical facilities might be limited.
Frequently Asked Questions
Q: What should I do if I suspect a finger fracture after an accident?
Look for symptoms such as pain, swelling, and loss of function. Check for abnormal mobility or deformity. If unsure, use X-rays to confirm the diagnosis.
Q: How can I prevent adhesions in my fingers during recovery from a fracture?
Begin guarded passive motion after 10 days to keep joints mobile and prevent adhesions between tendons and their sheaths. This helps maintain full range of motion post-recovery.
Q: What equipment is necessary for treating finger fractures at home?
Essential items include plaster splints, adhesive strips, cotton padding, and ethereal antiseptic soap for cleaning wounds. These can help in immobilizing the injured finger and preventing infection.