Discussion Author(s): Sean P. Leonard ENS MC USNR
This case demonstrates the critical importance of obtaining multiple radiographic views to evaluate for a fracture. On the AP radiograph, the lucent vertical fracture line of the distal phalanx of the 5th digit extending into the distal interphalangeal (DIP)joint is subtle. The full extent of the fracture is difficult to appreciate. The lateral and oblique radiographs clearly show the fracture and dorsal displacement of the avulsed fragment from the base of the distal phalanx. There is mild flexion deformity at the DIP joint. Flexion deformity at this joint (mallet finger)can result from partial or complete tear of the extensor tendon or an avulsion fracture at the insertion site of this tendon. Treatment usually involves splinting for approximately 6-12 weeks. However, since this injury involves the articular surface, more extensive treatment is necessary. With avulsive injuries to articular surfaces there is a need to reduce and fix internally the fracture in order to ensure joint integrity. In addition, since avulsion injuries involve ligaments and tendons, internal fixation helps restores function to those ligaments or tendons involved in the injury. In some cases, where the fracture involves one-quarter or less of the articular surface, treatment can be confined to open reduction with splinting in the anatomic position. The long-term outcomes for patients with intra-articular fractures of the phalanges are not always completely satisfactory. In one study, only 60% of patients regained full range of motion after the injury, and 17% showed radiographic evidence of post-traumatic arthritis.
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