Phalangeal fractures : epidemiology and new methods for treatment

<p dir="ltr">Finger fractures are very common and might affect hand function. Most finger fractures are treated non-surgically with plaster casts or immediate mobilization. Some, more complex, fractures need surgery to restore functionality. Surgery afflicts a new trauma to the already injured finger and give rise to soft tissue adhesions which restricts movement. This thesis aimed at describing the epidemiology of finger fracture and to evaluate different treatment methods.</p><p dir="ltr">In Paper I data from the Swedish Fracture Registry (SFR) which is a national quality registry that collects data from all orthopaedic trauma centres in Sweden, were analysed. 21 341 finger fractures were described regarding anatomical distribution, cause, treatment, age distribution, and result in terms of patient related outcome measures (PROMs). The most common finger fracture was one in the proximal phalanx of the 5^th finger. Fall accidents were the most common cause of fracture. The mean age at injury was 40 years (38 for men, 43 for women). 86% of finger fractures in adults were treated non-operatively. Finger fractures did not affect hand function or quality of life and there were no relevant differences in PROM between fracture type, treatment, or gender.</p><p dir="ltr">Paper II was an interim, non-inferiority analysis of a randomised controlled trial comparing percutaneous pinning and plaster immobilization versus non-surgical treatment using a custom-made orthosis and early mobilization of fractures in the proximal finger phalanx. A total of 42 fractures in 42 patients were included in the analysis. Baseline characteristics, including age, sex, and fracture displacement, were comparable between groups. There was no significant difference in the primary outcome, total active range of motion (TAM of the injured finger at 12 months. Non-surgical treatment with a custom-made splint and early mobilization was not inferior to surgical fixation.</p><p dir="ltr">To overcome the problem with soft tissue adhesions to osteosynthesis material in fracture surgery, a newly developed anti-adhesive moldable coating over metal plates was tested in Paper III. Using a rabbit model, coated plates were compared with bare plates regarding movement in rabbit toe joints. Macroscopically there were less adhesions around the coated plates. Joint movement in toes with coated plates was significantly better compared to bare plates. Coated plates were also easier to remove due to less soft tissue ingrowth.</p><p dir="ltr">In Paper IV another application of the material from study III was evaluated. Screws on either side of a fracture line was connected with the soft composite material. After curing with high energy light, a rigid osteosynthesis was achieved. Maximum load and bending rigidity of the custom-made plate was tested on porcine bones with transverse and multifragmented fractures. In a human cadaver model with fractures of the proximal phalanges the method proved stable enough for finger flexion movement. A rat femur fracture model showed that the material did not interfere with bone healing nor affected the surrounding soft tissues in a negative way.</p><p dir="ltr">In conclusion, most finger fractures are treated non-surgically and they usually do not have a large impact on patient reported outcomes. Some displaced fractures of the proximal phalanx can be treated non-surgically. The material described in Papers III and IV has promising features for fracture treatment in fingers, but further research is needed.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Alfort H,</b> von Kieseritzky J, Wilcke M. "Finger fractures: Epidemiology and treatment based on 21341 fractures from the Swedish Fracture register." PLOS One. 2023 Jul 14;18(7):e0288506. <a href="https://doi.org/10.1371/journal.pone.0288506" rel="noreferrer" target="_blank">https://doi.org/10.1371/journal.pone.0288506</a></p><p dir="ltr">II. <b>Alfort, H.</b>, von Kieseritzky, J. and Wilcke, M. "Percutaneous Pinning vs. Orthosis and Early Mobilization for Proximal Phalanx Fractures: A Randomized Controlled Trial - An interim analysis of 42 fractures". 2025. [Manuscript]</p><p dir="ltr">III. von Kieseritzky J, <b>Alfort H,</b> Granskog V, Hutchinson D, Stenlund P, Bogestål Y, Arner M, Håkansson J, Malkoch M. "DendroPrime as an adhesion barrier on fracture fixation plates: an experimental study in rabbits." J Hand Surg Eur Vol. 2020 Sep;45(7):742-747. <a href="https://doi.org/10.1177/1753193420932477" rel="noreferrer" target="_blank">https://doi.org/10.1177/1753193420932477</a></p><p dir="ltr">IV. Hutchinson, D. J., V. Granskog, J. von Kieseritzky, <b>H. Alfort</b>, P. Stenlund, Y. Zhang, M. Arner, J. Håkansson, M. Malkoch, "Highly Customizable Bone Fracture Fixation through the Marriage of Composites and Screws." Adv. Funct. Mater. 2021, 31, 2105187. <a href="https://doi.org/10.1002/adfm.202105187" rel="noreferrer" target="_blank">https://doi.org/10.1002/adfm.202105187</a></p>