Proximal phalanx (finger) fracture Contents 1 Background The flexor digitorum superficialis (FDS) inserts at the middle of the phalanx and can cause rotational deformity [1] Extensor tendons and interosseous muscles commonly causes volar angulation [1] Clinical Features Finger pain Differential Diagnosis Hand and Finger Fractures Percutaneous Reduction and Fixation of Displaced Phalangeal Neck Fractures in Children Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). Because it is the longest of the toe bones, it is the most likely to fracture. Radiographs are shown in Figure A. Am Fam Physician, 2003. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. Nail bed injury and neurovascular status should also be assessed. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. Pain is worsened with passive toe extension. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. He came to the ER at that point to be evaluated. Proximal articular. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Lgters TT, (OBQ18.111) Because it is the longest of the toe bones, it is the most likely to fracture. (Right) An intramedullary screw has been used to hold the bone in place while it heals. The most common injury in children is a fracture of the neck of the talus. Following reduction, the nail bed of the fractured toe should lie in the same plane as the nail bed of the corresponding toe on the opposite foot. And finally, the webinar will cover fixation techniques, including various instrumentation options.Moderator:Jeffrey Lawton, MDChief, Hand and Upper ExtremityProfessor, Orthopaedic SurgeryAssociate Chair for Quality and Safety, Orthopaedic SurgeryProfessor, Plastic SurgeryUniversity of MichiganAnn Arbor, MichiganFaculty: Charles Cassidy, MDHenry H. Banks Professor and ChairmanDepartment of OrthopaedicsTufts Medical CenterBoston, MassachusettsChaitanya Mudgal, MD, MS (Ortho), MChHand Surgery ServiceDepartment of OrthopedicsMassachusetts General HospitalChairman, AO NA Hand Education CommitteeAssociate Professor, Orthopedic Surgery, Harvard Medical SchoolBoston, MassachusettsAmit Gupta, MD, FRCSProfessorDepartment of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyRebecca Neiduski, PhD, OTR/L, CHTDean of the School of Health SciencesProfessor of Health SciencesElon UniversityElon, North Carolina, Ring Finger Proximal Phalanx Fracture in 16M. If the bone is out of place and your toe appears deformed, it may be necessary for your doctor to manipulate, or reduce, the fracture. Magnetic Resonance Imaging (MRI) scans. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . The fractures reviewed in this article are summarized in Table 1. If you need surgery it is best that this be performed within 2 weeks of your fracture. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Referral is indicated if buddy taping cannot maintain adequate reduction. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. Indications. Most commonly, the fifth metatarsal fractures through the base of the bone. Minimally displaced (less than 3 mm) avulsion fractures typically require immobilization and support with a short leg walking boot. and S. Hacking, Evaluation and management of toe fractures. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. However, overlying shadows often make the lateral view difficult to interpret (Figure 1, center). If you experience any pain, however, you should stop your activity and notify your doctor. Pearls/pitfalls. laceration bone talks, extensor tendon injuries hand orthobullets, flexor and extensor tendon injuries phoenix az arizona, tendon lacerations twin boro physical therapy, repair and rehabilitation of extensor hallucis longus and, extensor mechanism injury hip amp knee book, Sesamoid bones generally are present within flexor tendons in the first toe (Figure 1, top) and are found less commonly in the flexor tendons of other toes. We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. Toe fracture (Redirected from Toe Fracture) Contents 1 Background 2 Clinical Features 3 Differential Diagnosis 3.1 Foot and Toe Fractures 3.1.1 Hindfoot 3.1.2 Midfoot 3.1.3 Forefoot 4 Management 4.1 General Fracture Management 4.2 Immobilization 5 Disposition 6 See Also 7 References Background Bones of the foot. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. There should be at least three images of the affected toe, including anteroposterior, lateral, and oblique views, with visualization of the adjacent toes and of the joints above and below the suspected fracture location. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. The preferred splinting technique is to buddy tape the affected toe to an adjacent toe (Figure 7).4 Treatment should continue until point tenderness is resolved, usually at least three weeks (four weeks for fractures of the first toe). Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. A combination of anteroposterior and lateral views may be best to rule out displacement. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Copyright 2023 American Academy of Family Physicians. Copyright 2023 Lineage Medical, Inc. All rights reserved. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. (OBQ05.226) Healing time is typically four to six weeks. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. Healing rates also vary considerably depending on the age of the patient and comorbidities. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. The metatarsals are the long bones between your toes and the middle of your foot. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. When this happens, surgery is often required. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. (OBQ11.63) Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. (Kay 2001) Complications: If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. This joint sits between the proximal phalanx and a bone in the hand . Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. Patients with Jones fractures should be referred if there is more than 2 mm of displacement, if conservative therapy is ineffective after 12 weeks of immobilization and radiography reveals nonunion, or if the patient is an athlete or is highly active.2,13,2022, Toe fractures are the most common fractures of the foot.23,24 Most fractures involve minimal displacement and are treated nonsurgically. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). angel academy current affairs pdf . A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. Analytical, Diagnostic and Therapeutic Techniques and Equipment 43. Continue to learn and join meaningful clinical discussions . Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. Copyright 2023 Lineage Medical, Inc. All rights reserved. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. . Interosseus muscles and lumbricals insert onto the base of the proximal phalanx and flex the proximal fragment. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. J AmAcad Orthop Surg, 2001. Proximal hallux. Dislocation refers to displacement in which the two articular surfaces are no longer in contact, in contrast to subluxation, in which there is some contact (may be referred to as complete versus simple dislocation in some texts). While many Phalangeal fractures can be treated non-operatively, some do require surgery. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Joint hyperextension and stress fractures are less common. The fifth metatarsal is the long bone on the outside of your foot. In some cases, a Jones fracture may not heal at all, a condition called nonunion. Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). Advertisement Almost two-thirds of all bones in the feet belong to the toes; hence the risk of fracture in this part of the foot is much higher than the rest of the foot. Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. Comminution is common, especially with fractures of the distal phalanx. Most broken toes can be treated without surgery. Radiographs often are required to distinguish these injuries from toe fractures. ClinPediatr (Phila), 2011. Injury. Clinical Features Content is updated monthly with systematic literature reviews and conferences. Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. You can rate this topic again in 12 months. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Started in 1995, this collection now contains 6407 interlinked topic pages divided into a tree of 31 specialty books and 722 chapters. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. Diagnosis is made with plain radiographs of the foot. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. All Rights Reserved. Which of the following is true regarding open reduction and screw fixation of this injury? Illustrations of proximal interphalangeal joint (PIPJ) fracture-dislocation patterns. 118(2): p. e273-8. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. For acute metatarsal shaft fractures, indications for surgical referral include open fractures, fracture-dislocations, multiple metatarsal fractures, intra-articular fractures, and fractures of the second to fifth metatarsal shaft with at least 3 mm displacement or more than 10 angulation in the dorsoplantar plane. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. toe phalanx fracture orthobullets AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. A fractured toe may become swollen, tender, and discolored. Epidemiology Incidence Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. After anesthetizing the toe with ice or a digital block, the physician holds the tip of the toe, applies longitudinal traction, and manipulates the bone fragments into proper position. Surgeons will learn to assess and evaluate phalangeal anatomy and fracture geometry. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. All the bones in the forefoot are designed to work together when you walk. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. Jones fractures are located in a watershed area for blood supply (zones 2 and 3) and have high rates of delayed union and nonunion17 (Figure 10). Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Kay, R.M. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. Patient examination; . At the first follow-up visit, radiography should be performed to assure fracture stability. The proximal phalanx is the toe bone that is closest to the metatarsals. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. Copyright 2023 Lineage Medical, Inc. All rights reserved. Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensation an indication of nerve injury, Head which makes a joint with the base of the toe, Neck the narrow area between the head and the shaft, Base which makes a joint with the midfoot. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. (OBQ09.156) Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Common mechanisms of injury include: Axial loading (stubbing toe) Abduction injury, often involving the 5th digit Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot Less common mechanism: (OBQ12.89) Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD. These tendons may avulse small fragments of bone from the phalanges; they also can be injured when a toe is fractured. Your foot may become swollen and discolored after a fracture. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. toe phalanx fracture orthobulletsdaniel casey ellie casey. Rotator Cuff and Shoulder Conditioning Program. Copyright 2023 American Academy of Family Physicians. (Left) The four parts of each metatarsal. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. Returning to activities too soon can put you at risk for re-injury. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Copyright 2016 by the American Academy of Family Physicians. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Treatment Most broken toes can be treated without surgery. Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Fractures in this area can occur anytime there is a break in the compact bone matrix that makes up the proximal phalanx. The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. imbalance after flexor tendon repair seems to be thus, extensor tendon injuries occur frequently an in depth understanding of the intricate anatomy of the extensor mechanism is necessary to guide management careful counseling is helpful in Proximal metaphyseal. In children, toe fractures may involve the physis (Figure 2). Your next step in management should consist of: Percutaneous biopsy and referral to an orthopaedic oncologist, Walker boot application and evaluation for metabolic bone disease, Referral to an orthopaedic oncologist for limb salvage procedure, Internal fixation of the fracture and evaluation for metabolic bone disease, Metatarsal-cuneiform fusion of the Lisfranc joint. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface (Figure 3) usually do not require referral and can be managed using the methods described in this article. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). A fracture, or break, in any of these bones can be painful and impact how your foot functions. If there is a break in the skin near the fracture site, the wound should be examined carefully. All rights reserved. The talus has a head, constricted neck, and body. Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. stress fracture of the proximal phalanx MRI indications positive bone scan hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture abnormal radiographs persistent pain, swelling, weak toe push-off not recommended routinely findings will show disruption of volar plate Taping may be necessary for up to six weeks if healing is slow or pain persists. PMID: 22465516. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Plate fixation . The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). Toe and forefoot fractures often result from trauma or direct injury to the bone. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. and C.W. Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. Author disclosure: No relevant financial affiliations. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? This webinar will address key principles in the assessment and management of phalangeal fractures. Lesser toe fractures are about twice as common as great toe fractures.23,24 The great toe has an increased role in weight bearing and balance; thus, injury to the great toe is associated with higher morbidity.6,24, The primary goals of treating toe fractures include reestablishing and maintaining alignment, regaining range of motion, and preventing complications. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Management of Proximal Phalanx Fractures Management of Proximal Phalanx Fractures & Their Complications. During this time, it may be helpful to wear a wider than normal shoe. If the bone is out of place, your toe will appear deformed. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. X-rays. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. Unlike an X-ray, there is no radiation with an MRI. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. This information is provided as an educational service and is not intended to serve as medical advice. fractures of the head of the proximal phalanx. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. If you have an open fracture, however, your doctor will perform surgery more urgently. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Patients with intra-articular fractures are more likely to develop long-term complications. Copyright 2023 Lineage Medical, Inc. All rights reserved. The proximal phalanx is the toe bone that is closest to the metatarsals. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. Hand (N Y). Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. Non-narcotic analgesics usually provide adequate pain relief. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. If the bone is out of place, your toe will appear deformed. Thank you. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. This webinar will address key principles in the assessment and management of phalangeal fractures. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease).