Abstract
Background:
Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures.
Methods:
A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information.
Results:
The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to “stiffness/tendon adhesion” (50%) and “nonunion or delayed union” (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers’ fractures were found to be independently associated with unplanned reoperation.
Conclusions:
Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.
Keywords: phalangeal fracture, reoperation, epidemiology, research and health outcomes, complications, vascular repair
Introduction
Phalangeal fractures comprise almost a quarter of all upper extremity fractures seen in emergency departments in the United States and are one of the most expensive injury types annually with high costs due to lost productivity.1,2 These types of fractures can occur in various anatomic locations (ie, different digits and phalanges) and fracture patterns. Other characteristics of fractures—such as articular involvement, dislocation of the fractured phalanx, and the presence of comminution—affect fracture stability, which typically dictates treatment for phalangeal fractures, particularly regarding the decision for operative management.3,4
Traumatic injuries leading to fracture of the phalanges may also cause vascular compromise with acute ischemia of the affected digit, even in cases without traumatic amputation of the digit. These injuries require surgical intervention to restore perfusion to the dysvascular digit and attempt to minimize complications such as poor bone healing.5-8 Previous studies examining the outcomes of such fractures are all in pediatric population with small sample sizes (<20 patients) and describe an increased number of complications, rate of nonunion, and need for reoperation.6,7,9,10 Therefore, a larger study that includes adult patients would be informative for an improved understanding of the patient population, outcomes, and locations of these fractures to better prevent them and aid their management. The purpose of this study was to evaluate an adult patient cohort in the United States with phalangeal fractures to: (1) report patient and injury characteristics of fractures with vascular compromise; and (2) to identify predictors for reoperation in this population.
Materials and Methods
Patient Cohort
Approval from the institutional review board was obtained to perform this retrospective cohort study. This study included adult, non-pregnant patients who underwent surgical or conservative treatment of a traumatic phalangeal fracture between January 1, 2010, and January 1, 2015, at 2 level I trauma centers in the Northeastern United States. Patients with traumatic digital amputations were not included in this cohort. Thus, an overall total of 2140 phalangeal fractures in 1747 patients who met the inclusion criteria were identified using Current Procedural Terminology (CPT) codes (Supplemental Table S1). Fractures that were associated with vascular injury resulting in dysvascularity of the digit were further identified using additional CPT codes (Supplemental Table S2) and confirmed by medical chart review. Fractures for which revision amputation was performed as the primary surgery were excluded as these injuries fell out of the scope of this study. A total of 54 phalangeal fractures that underwent vascular repair or reconstruction synchronously with bony fixation were identified in 48 patients, and the prevalence of these fractures was expressed as a percentage of the total cohort of phalangeal fractures (n = 2140) during the studied timeframe. This cohort may partially overlap with patients included in prior publications, which studied different research questions.11-14
Data Collection
A manual chart review was performed to collect radiographic information and characterize the fractures, and to gather data on patient and treatment characteristics. The collected fracture information included the affected hand, digit, and phalanx, and whether the dominant hand was affected; characteristics such as articular involvement, dislocation, open fractures, and comminution; the location (base, tuft, shaft, neck, head) and type (transverse, oblique, spiral, vertical, dorsal base, volar base, radial/ulnar base, unicondylar, bicondylar, tuft) of the fracture; the trauma mechanism (crush, sharp, explosion, impact, other) and whether it was work-related; and the date of injury and date of last follow-up by a hand surgeon. Also determined was the presence or absence of nerve injury, flexor tendon injury, extensor tendon injury, and ligamentous injury (eg, volar plate) in the same digit as the phalangeal fracture. A “complex multilevel” fracture pattern was assigned to fractures extending through multiple regions of a phalanx and an “indiscernible” to those without a recognizable pattern. The interpretation of the radiologist was used for this classification. If a clear classification was lacking in the report of the radiograph, the fracture was classified by one or more researchers until consensus was reached.
Various patient characteristics were also collected such as the date of birth, sex, tobacco use, presence of diabetes, type of insurance (private, Medicare, Medicaid, self-pay), and race (White, Asian, Hispanic, Black, Other). We also used the definition by Newington et al 15 to determine whether a patient engages in manual labor.
Collected data regarding the treatment included the date and type of surgery (Kirschner-wire [K-wire] fixation, plate fixation, lag screw, and other), the occurrence and type of surgical complications as described by Kootstra et al 16 (pain, stiffness/tendon adhesion non/delayed union, loss of fixation, infection, wound dehiscence, and other), and the date and type of reoperations (tenolysis/capsulotomy, incision and drainage, debridement, hardware removal, revision fixation, change in fixation method, amputation, other) if these were performed.
Statistical Analysis
Statistical analysis was performed using Stata/IC 16.1 (StataCorp., College Station, TX). The normality of data was assessed using visual inspection in histograms and the Shapiro-Wilk test. Categorical data were described as frequencies and percentages, and continuous data were described using medians with interquartile ranges (IQRs). The Fisher exact test (for dichotomous explanatory variables) and Mann-Whitney U test (for continuous explanatory variables) were used to determine risk factors associated with reoperation in bivariate analysis. Variables with a P value of less than .10 in bivariate analysis were entered in a multivariable logistic regression model to identify independent predictors for reoperation. A P value of less than .05 was considered significant in the multivariable model.
Results
Patient Demographics
A total of 54 phalangeal fractures (2.5%) from the total cohort of 2140 fractures were identified as having vascular injury requiring treatment and were subsequently analyzed. The 54 fractures occurred in 48 patients, with 1 patient sustaining 3 phalangeal fractures, 4 patients (8.3%) sustaining 2 fractures, and 43 patients (89.6%) sustaining a single fracture. The median age at the time of injury was 46.9 years (IQR: 29.1-56.6), and 89.6% of patients were men. Fifty-six percent of patients were employed in manual labor, 43.5% of patients were smokers, and 6.3% had diabetes at the time of injury. Further data on demographics are presented in Table 1.
Table 1.
Demographics of Phalangeal Fractures Requiring Vascular Repair.
| Variable | Incidence |
|---|---|
| Fracture with vascular injury requiring repair, n (%) | 54 (2.52) |
| Fracture without vascular injury, n (%) | 2086 (97.5) |
| Demographics of patients with dysvascular fractures | |
| Age at injury in years, median (IQR) | 46.9 (29.1-56.6) |
| Age at last follow-up in years, median (IQR) | 49.2 (30.0-58.3) |
| Male sex, n (%) a | 43 (89.6) |
| Smoker, n (%) a | 20 (43.5) |
| Diabetes, n (%) a | 3 (6.25) |
| Manual labor, n (%) a | 24 (55.8) |
| Race a | |
| White, n (%) | 37 (77.1) |
| Hispanic, n (%) | 3 (6.25) |
| Black, n (%) | 1 (2.08) |
| Other, n (%) | 7 (14.6) |
| Insurance type a | |
| Private, n (%) | 19 (54.3) |
| Medicare, n (%) | 2 (5.71) |
| Medicaid, n (%) | 8 (22.9) |
| Self-pay, n (%) | 6 (17.1) |
Note. Missing values per variable: smoker (2); manual labor (5); insurance (13). IQR = interquartile range.
Per-patient analysis.
Injury Characteristics
Thirty-five percent of fractures requiring vascular repair occurred in the dominant hand (Table 2). The middle finger was most often involved, accounting for 29.6% of fractures, followed by the index (22.2%) and ring (20.4%) fingers. The proximal phalanx was the location of most fractures (59.3%), followed by the middle phalanx (29.6%). In terms of fracture location within each phalanx, the phalangeal shaft was most often injured (46.3%), followed by a complex multilevel fracture (extending through multiple parts of the phalanx, 18.2%) and the phalangeal base (16.7%). The most common fracture type was transverse (29.6%), followed by oblique (27.8%). More than one-third of the fractures (38.9%) were associated with an intra-articular fracture pattern, 57.4% occurred as an injury in which multiple digits were affected (although not each of these injuries were necessarily associated with vascular injury of that digit), 13% occurred in a digit in which multiple phalanges were injured, and in 5.56%, the fractured phalanx was also dislocated. In the affected digit, 57.4% of fractures were associated with a nerve injury, 50.0% with a flexor tendon injury, 25.9% with an extensor tendon injury, and 13.0% with a documented ligament injury. More than half of the fractures were due to occupational injury (52.9%), and the most common injury mechanism was sharp (68.5%), followed by crush (25.9%).
Table 2.
Injury Characteristics.
| Variable | Incidence |
|---|---|
| Right hand affected, n (%) | 16 (29.6) |
| Left hand affected, n (%) | 38 (70.4) |
| Digit | |
| Thumb, n (%) | 8 (14.8) |
| Index, n (%) | 12 (22.2) |
| Middle, n (%) | 16 (29.6) |
| Ring, n (%) | 11 (20.4) |
| Little, n (%) | 7 (13.0) |
| Phalanx | |
| Proximal, n (%) | 32 (59.3) |
| Middle, n (%) | 16 (29.6) |
| Distal, n (%) | 6 (11.1) |
| Location | |
| Base, n (%) | 9 (16.7) |
| Tuft, n (%) | 2 (3.70) |
| Shaft, n (%) | 25 (46.3) |
| Neck, n (%) | 6 (11.1) |
| Head, n (%) | 2 (3.70) |
| Complex multilevel fracture, n (%) | 10 (18.5) |
| Type | |
| Transverse, n (%) | 16 (29.6) |
| Oblique, n (%) | 15 (27.8) |
| Spiral, n (%) | 0 |
| Vertical, n (%) | 0 |
| Dorsal avulsion, n (%) | 3 (5.56) |
| Volar avulsion, n (%) | 3 (5.56) |
| Lateral avulsion, n (%) | 3 (5.56) |
| Unicondylar, n (%) | 1 (1.85) |
| Bicondylar, n (%) | 1 (1.85) |
| Tuft, n (%) | 2 (3.70) |
| Indiscernible, n (%) | 10 (18.5) |
| Intra-articular, n (%) | 21 (38.9) |
| Occupation-related injury, n (%) | 27 (52.9) |
| Dominant hand affected, n (%) | 18 (34.6) |
| Multiple digits affected, n (%) | 31 (57.4) |
| Multiple phalanges in same digit affected, n (%) | 7 (13.0) |
| Nerve affected, n (%) a | 31 (57.4) |
| Flexor tendon affected, n (%) a | 27 (50.0) |
| Extensor tendon affected, n (%) a | 14 (25.9) |
| Ligament affected, n (%) a | 7 (13.0) |
| Fracture-dislocation, n (%) | 3 (5.56) |
| Injury mechanism | |
| Crush, n (%) | 14 (25.9) |
| Sharp, n (%) | 37 (68.5) |
| Explosion, n (%) | 2 (3.70) |
| Other, n (%) | 1 (1.85) |
Note. Missing values per variable: occupation-related injury (3); dominant hand affected (2).
All structures affected are in the same digit as the fracture.
Surgical Intervention and Complications
Most fractures underwent K-wire fixation (90.7%), with the remaining fractures being repaired by plate fixation (9.26%; Table 3). Seven digits (13%) required a vein graft for vascular repair. One digit (1.85%) and 5 digits (9.26%) underwent repair of nerve injury with a nerve conduit and nerve allograft, respectively. One primary complication was collected for each fracture for which a secondary surgery was required, which was most commonly stiffness/tendon adhesion (50%), followed by nonunion or delayed union (21.4%), infection (7.14%), and pain (7.14%). More than half of the fractures underwent a secondary surgery (51.9%), with 12 fractures (22.2%) requiring 2 reoperations, and 3 fractures (5.55%) requiring 3 or more reoperations. Of all reoperations, the most common type was tenolysis/capsulotomy (44.9%), followed by hardware removal and secondary amputation (both of which occurred in 6 fractures, 12.2%).
Table 3.
Surgical Intervention and Complications.
| Variable | Incidence |
|---|---|
| Type of fracture fixation | |
| Wire fixation, n (%) | 49 (90.7) |
| Plate fixation, n (%) | 5 (9.26) |
| Neurovascular repair a | |
| Nerve affected, n (%) | 31 (57.4) |
| Nerve graft needed, n (%) | 1 (1.85) |
| Nerve conduit needed, n (%) | 5 (9.26) |
| Vein graft needed, n (%) | 7 (13.0) |
| Primary complications b | |
| Pain, n (%) | 2 (7.14) |
| Stiffness/tendon adhesion, n (%) | 14 (50.0) |
| Nonunion or delayed union, n (%) | 6 (21.4) |
| Loss of fixation, n (%) | 1 (3.57) |
| Infection, n (%) | 2 (7.14) |
| Wound dehiscence, n (%) | 1 (3.57) |
| Other, n (%) | 2 (7.14) |
| Reoperation number | |
| 0 reoperations, n (%) | 26 (48.1) |
| 1 reoperation, n (%) | 13 (24.1) |
| 2 reoperations, n (%) | 12 (22.2) |
| ≥3 reoperations, n (%) | 3 (5.55) |
| Reoperation type b | |
| Tenolysis/capsulotomy, n (%) | 22 (44.9) |
| Incision and drainage, n (%) | 1 (2.04) |
| Debridement, n (%) | 4 (8.16) |
| Hardware removal, n (%) | 6 (12.2) |
| Revision fixation, n (%) | 2 (4.08) |
| Change in fixation method, n (%) | 2 (4.08) |
| Amputation, n (%) | 6 (12.2) |
| Other, n (%) | 6 (12.2) |
All structures affected are in the same digit as the fracture.
Frequency and percentages based on total number of complications (28) and reoperations (49).
Predictors of Secondary Surgery
Bivariate analysis was used to identify factors associated with reoperation of phalangeal fractures that underwent concomitant vascular repair (Table 4). Fractures in the proximal phalanx were more likely to undergo reoperation (65.6%, P = .05), as well as fractures in the index finger (75.0%, P = .07) in comparison with the other phalanges and digits, respectively. Patients who were active smokers at the time of injury were found to be less likely to undergo reoperation (38.1%, P = .09). In multivariable analysis correcting for smoking status, digit, and phalanx fracture location, the affected digit was found to be an independent predictor of reoperation, with injury to the thumb (odds ratio [OR]: 35.10; 95% confidence interval [CI]: 1.1-1096.7; P = .043) and index finger (OR: 14.00; 95% CI: 1.0-191.3; P = .048) significantly associated with a higher likelihood of secondary surgery (Table 5).
Table 4.
Bivariate Analysis of Factors Associated With Reoperation.
| Variable | Reoperation—Yes | Reoperation—No | P value |
|---|---|---|---|
| Age at injury in years, median (IQR) | 42.7 (28.4-55.3) | 48.8 (30.0-62.8) | .48 |
| Male sex, n (%) a | 27 (55.1) | 22 (44.9) | .18 |
| Smoker, n (%) | 8 (38.1) | 13 (61.9) | .09 |
| Diabetes, n (%) | 3 (75.0) | 1 (25.0) | .61 |
| Manual labor, n (%) | 16 (61.5) | 10 (38.5) | .40 |
| Digit | .07 | ||
| Thumb, n (%) | 5 (62.5) | 3 (37.5) | |
| Index, n (%) | 9 (75.0) | 3 (25.0) | |
| Middle, n (%) | 6 (37.5) | 10 (62.5) | |
| Ring, n (%) | 7 (63.6) | 4 (36.4) | |
| Little, n (%) | 1 (14.3) | 6 (85.7) | |
| Phalanx | .05 | ||
| Proximal, n (%) | 21 (65.6) | 11 (34.4) | |
| Middle, n (%) | 6 (37.5) | 10 (62.5) | |
| Distal, n (%) | 1 (16.7) | 5 (83.3) | |
| Location | .90 | ||
| Base, n (%) | 3 (33.3) | 6 (66.7) | |
| Shaft, n (%) | 15 (57.7) | 11 (42.3) | |
| Neck, n (%) | 3 (50) | 3 (50) | |
| Head, n (%) | 1 (50) | 1 (50) | |
| Tuft, n (%) | 1 (50) | 1 (50) | |
| Complex multilevel fracture, n (%) | 6 (60) | 4 (40) | |
| Type | .70 | ||
| Transverse, n (%) | 9 (56.3) | 7 (43.8) | |
| Oblique, n (%) | 8 (53.3) | 7 (46.7) | |
| Spiral, n (%) | NA | NA | |
| Vertical, n (%) | NA | NA | |
| Dorsal avulsion, n (%) | 1 (33.3) | 2 (66.7) | |
| Volar avulsion, n (%) | 0 | 3 (100) | |
| Lateral avulsion, n (%) | 2 (66.7) | 1 (33.3) | |
| Unicondylar, n (%) | 1 (100) | 0 | |
| Bicondylar, n (%) | 0 | 1 (100) | |
| Tuft, n (%) | 1 (50) | 1 (50) | |
| Indiscernible, n (%) | 6 (60) | 4 (40) | |
| Intra-articular, n (%) | 12 (57.1) | 9 (42.9) | .59 |
| Occupation-related injury, n (%) | 16 (59.3) | 11 (40.7) | .58 |
| Dominant hand affected, n (%) | 9 (50.0) | 9 (50.0) | .77 |
| Nerve affected, n (%) | 17 (54.8) | 14 (45.2) | .78 |
| Flexor tendon affected, n (%) | 16 (59.3) | 11 (40.7) | .41 |
| Extensor tendon affected, n (%) | 7 (50.0) | 7 (50.0) | > .99 |
| Ligament affected, n (%) | 5 (71.4) | 2 (28.6) | .42 |
| Fracture-dislocation, n (%) | 1 (33.3) | 2 (66.7) | .60 |
| Injury mechanism | .63 | ||
| Crush, n (%) | 9 (64.3) | 5 (35.7) | |
| Sharp, n (%) | 17 (46.0) | 20 (54.1) | |
| Explosion, n (%) | 1 (50.0) | 1 (50.0) | |
| Other, n (%) | 1 (100) | 0 | |
| Type of fracture fixation | .83 | ||
| Wire fixation, n (%) | 25 (52.1) | 23 (47.9) | |
| Plate fixation, n (%) | 2 (40.0) | 3 (60.0) | |
| Other, n (%) | 1 (100) | 0 | |
| Neurovascular repair | |||
| Nerve graft needed, n (%) | 0 | 1 (100) | .48 |
| Nerve conduit needed, n (%) | 1 (20) | 4 (80.0) | .18 |
| Vein graft needed, n (%) | 4 (57.1) | 3 (42.9) | > .99 |
Note. P values of <.10 were considered significant in this bivariate analysis and are reported in boldface. IQR = interquartile range; NA = not applicable.
Per-patient analysis.
Table 5.
Logistic Multivariable Analysis for Reoperation.
| Characteristic | OR | SE | 95% CI | P value |
|---|---|---|---|---|
| Smoker | 0.28 | 0.20 | 0.07-1.17 | .08 |
| Digit | ||||
| Thumb | 35.10 | 61.60 | 1.12-1097 | .043 |
| Index | 14.00 | 18.70 | 1.03-191 | .048 |
| Middle | 2.94 | 3.69 | 0.25-34.3 | .39 |
| Ring | 10.20 | 13.80 | 0.73-144 | .09 |
| Little | Reference | |||
| Phalanx | ||||
| Proximal | 15.50 | 21.70 | 0.99-242 | .05 |
| Middle | 6.45 | 9.87 | 0.32-130 | .22 |
| Distal | Reference | |||
Note. P values of <.05 were considered significant and are boldface. OR = odds ratio; CI = confidence interval.
Discussion
This study evaluates 54 phalangeal fractures that underwent vascular repair due to ischemia to understand patient and fracture characteristics, as well as outcomes after surgical management and risk factors for reoperation. The 54 fractures constituted 2.52% of all phalangeal fractures in the same timeframe. More than half of these fractures underwent at least one reoperation, which makes this a considerable injury type as most upper extremity procedures have an unplanned reoperation rate of less than 1%. 17
Most of the patients with these injuries were men (89.6%) and nearly half (40.4%) were smokers at the time of injury. Epidemiologic studies analyzing all phalangeal fractures (both those with and without vascular injury) have demonstrated a slightly higher incidence in men in the adult population.18-20 The largest known analysis of phalangeal fractures with concomitant vascular injury (n = 16) by Al-Qattan 9 included only pediatric patients and did not list patients’ sex. In this study, the abundance of male patients among those affected by this type of injury in comparison with phalangeal fractures in general may potentially be explained by men being involved in activities that expose them to specific mechanisms of trauma.
We found that 52.9% of fractures were due to occupational injury. The Al-Qattan pediatric study found that all 16 patients had fractures due to crush injury (trapped by heavy objects), 9 which differs from the most common mechanism found in this cohort, which was sharp injury (68.5%). The Al-Qattan findings are consistent with general phalangeal fracture epidemiology studies, which cite crush injury as a common mechanism for children.18,21 However, our results highlight the differences in patient profile and injury mechanism among adult patients sustaining phalangeal fractures without vascular injury compared with those with vascular injury; although a blunt trauma mechanism is the most common cause of phalangeal fractures in general, 22 fractures with concomitant vascular injury appear to be most common in manual laborers using sharp objects. These findings suggest that the mechanism of injury could be more likely the cause of vascular injury than the fracture itself. Efforts to enhance and enforce safety measures in the occupational setting may prove useful in preventing these types of injuries. This is especially important considering that half of these injuries undergo at least one reoperation, placing a considerable strain on health care systems and resources.
The incidence of these phalangeal fractures was higher in the non-dominant hand (65.4%), and more commonly affected the middle finger (29.6%), proximal phalanx (59.3%), and phalangeal shaft (46.3%). This first-mentioned finding may reflect the large number of work-related fractures in this cohort, as the non-dominant hand may have increased exposure to injury due to occupational trauma mechanisms (such as holding a plank while using a saw). The Al-Qattan study did not report hand dominance and all fractures (n = 16) affected the phalangeal neck due to their inclusion criteria—however, there was an equal distribution of patients with proximal phalanx versus middle phalanx injuries (n = 8 each), and injury affecting all digits except for the ring finger (little n = 5, ring n = 0, middle n = 5, index n = 2, thumb n = 4). 9 It is difficult to compare our study as the sample size is small, but our findings of increased incidence in the proximal phalanx, middle finger, and phalangeal shaft may illustrate that these dysvascular fractures in the adult population have a similar distribution to phalangeal fractures in general (for both children and adults) regarding the affected digits and phalanges as well as fracture pattern.18,22 However, although phalangeal neck fractures are relatively rare in adults, 23 11.1% of factures in this cohort occurred in this location. In the overall cohort of phalangeal fractures (n = 2140), 6.52% of neck fractures were associated with vascular injury requiring repair, relative to head (1.68%), shaft (3.26%), base (1.33%), tuft (0.51%), and complex multilevel (11.5%, P < .001) fractures. Thus, both phalangeal neck fractures and phalangeal complex multilevel fractures should raise concern for concomitant vascular injury and thus warrant close inspection of the affected digit’s vascular status.
All included fractures underwent surgical intervention to address both their osseous and vascular injuries, the most common of which was K-wire fixation (88.9%) for bony fixation, consistent with that found in the Al-Qattan study (10 of 16). All patients also underwent vascular reconstruction with 13% of dysvascular fractures necessitating a vein graft. In bivariate analysis, injuries that needed a vein graft for vascular reconstruction did not appear to be more likely to undergo reoperation (57.1% vs 42.9%, P > .99). Although this study may be underpowered to detect this finding, it corroborates the similar functional outcomes and survival rate seen with and without vein grafts for vascular repair in finger replantation. 24 Also, more than half of the fractures had a concurrent nerve injury in the affected digit, with 11.1% undergoing nerve reconstruction by means of nerve allograft or nerve conduit, and half of the fractures had an associated flexor tendon injury. However, fractures with additional non-osseous injuries were not more likely to undergo reoperation in this cohort (based on bivariate analysis) although this finding may be limited due to small sample size.
The most common complication in this cohort was stiffness/tendon adhesion (50%). This was also the most common complication in both pediatric and adult phalangeal fracture studies.25-27 The next most common complication was nonunion or delayed union (21.4% of all complications that required reoperation) which is greatly increased from the rate seen in other studies (ie, studies including phalangeal fractures regardless of vascular injury), 10 and may be due to diminished perfusion subsequent to vascular compromise. Another explanation for this larger rate is the increased frequency of phalangeal neck fractures in this cohort, as this fracture type is reported to be more prone to nonunion in general. 23 It is also higher than the rate reported for the pediatric population (which had nonunion in 1 of 16 cases), which might be explained by the slower rate of healing in adults as compared with the pediatric population, as well as differences in the mechanisms of injury.9,28 More than half of the fractures (51.9%) required at least one reoperation while the reoperation rate reported in a general phalangeal fracture study ranged from 15% to 40%. 25 Although a causal relationship cannot be established through the current study, the potential mechanisms potentially underlying this difference are various. Examples include the unstable nature of phalangeal shaft and neck fractures (which comprise the largest subgroup in this cohort), 24 as well as ischemia which may also contribute to this increased percentage. A slower rehabilitation due to vascular and nerve repair may also increase the risk of stiffness/tendon adhesion. Notably, 12.2% of reoperation procedures were amputations, indicating that a considerable proportion of digits became nonviable or dysfunctional after primary surgery. Of the 6 patients who underwent subsequent amputations, 5 had either nonunion/delayed union or unsuccessful revascularization, and 4 of these 5 had shaft or complex multilevel fractures. This may be helpful in aiding future clinical decision-making for surgeons when deciding between amputation and fixation with revascularization for phalangeal fractures with concomitant vascular injury.
In bivariate analysis, reoperation was associated with the injured phalanx (P = .05), with the highest incidence of reoperations being found in the proximal phalanx (62.5% of all proximal phalanx fractures) compared with the middle (37.5%) and distal (16.7%) phalanges. Proximal phalangeal injuries approached significance for reoperation in multivariable analysis (P = .051). Most fractures in this location underwent secondary surgery (65.6%). Furthermore, 47.6% of proximal phalanx fractures with a reoperation noted stiffness/tendon adhesion as a complication. This finding may reflect the increased risk of complications (especially stiffness) that occur with injury to the zone II flexor tendon region. 29 Thus, the relatively high rate of reoperation for fractures in this location may implicate a poorer prognosis due to its location, rather than the extent of vascular compromise.
In multivariable regression analysis, both the thumb (OR: 35.1, P = .043) and index finger (OR: 14.0, P = .048) were independent factors associated with reoperation, with fractures in these digits more likely to undergo reoperation. Given that these 2 digits are important to the pinch grip, which is used often in manual labor (which applies to more than half of the patients in this cohort), these digits could be more likely to be subject to severe trauma secondary to occupational injury. Performing pinch and grip function too soon after initial surgery may also predispose to poor injury healing and a resulting need for secondary surgery. 30 In addition, the tolerance of patients with functional deficits may be smaller in these digits compared with digits that play a smaller role in daily activities.
The results of this study must be interpreted in the context of its limitations. First, as a retrospective study, CPT codes were used to identify all patients who underwent treatment (either surgical or conservative) for phalangeal fractures, and were also further used to identify the subgroup that was treated for vascular injury at the time of fracture. Because of this, it is possible that the incidence of dysvascular phalangeal fractures is higher than presented, due to miscoded or non-coded injuries. However, all dysvascular fractures that were identified by CPT codes were manually confirmed during medical chart review, likely obviating the possibility of overestimation. Second, all traumatic amputations were excluded from this study: Given that many patients with vascular compromise during phalangeal fracture have complete amputations, 31 the cohort presented in this study reflects the demographics and outcomes of a smaller group (ie, no amputation and therefore probably a less severe injury) within the entire group of phalangeal fractures that are associated with vascular injury. Although we do not have any data to suggest that inclusion of amputations would have had an effect on overall patient and injury characteristics, it may have had an impact on complications and reoperation rates, given different complication likelihoods for surgical fixation (eg, stiffness) versus revision for traumatic amputation (eg, paresthesia, hypersensitivity, ischemia).31,32 Third, all patients in this cohort were treated at 1 of 2 level I trauma centers in the same metropolitan area, and therefore there may be a selection bias regarding more extensive injuries, which may not be generalizable to all hospitals in the United States. Finally, follow-up was defined as time to last documentation in the chart for their injury, and some patients who live further away from the trauma center in which they were treated may have received further follow-up care at an outside hospital, in which case, a complication would perhaps not be recorded in the medical charts of our institutions.
In conclusion, this study examined the patient, fracture, and surgery characteristics for non-amputation phalangeal fractures requiring vascular repair in a US adult population. Unplanned reoperations are common following this injury, occurring in more than half of the fractures. More specifically, fractures of the thumb and index finger were found to be independently associated with an increased risk of unplanned reoperation, which may necessitate closer peri-operative attention for fractures with vascular compromise in these locations. Considering that a substantial proportion of these injuries is sustained in an occupational setting by patients who work in manual labor, efforts to reduce the incidence of these fracture types (eg, safety mechanisms on tools) could help limit the personal and societal burden of these injuries. The finding that roughly 1 in 10 secondary surgeries was a secondary amputation highlights the need for more accurate predictions of whether a digit affected by this type of injury is (functionally) salvageable. Although the reoperation rate and factors associated with reoperation were examined in this relatively large cohort, future research may benefit from including even more patients, perhaps through multicenter collaboration, to enable further analysis on risk factors for both specific complication types and secondary amputation.
Supplemental Material
Supplemental material, sj-docx-1-han-10.1177_15589447221109635 for Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation by Hannah J. Szapary, Mara Z. Meulendijks, Steven P. Moura, Anamika Veeramani, Barbara Gomez-Eslava, Yannick A. J. Hoftiezer, Neal C. Chen and Kyle R. Eberlin in HAND
Footnotes
Supplemental material is available in the online version of the article.
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: All procedures were completed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. The study was approved by the institutional review board of our institution under protocol number 2019P000635.
Statement of Informed Consent: This study was exempt from obtaining informed consent.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.R.E. is a consultant for AxoGen, Integra, and Checkpoint. N.C.C. is a consultant for Biedermann Motech. The rest of the authors declare that they have no conflicts of interest.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was in part supported by the Jesse B. Jupiter Research Fund of the Wyss Medical Foundation.
ORCID iDs: Mara Z. Meulendijks 
https://orcid.org/0000-0002-2900-6938
Barbara Gomez-Eslava
https://orcid.org/0000-0002-1597-5519
Yannick A. J. Hoftiezer
https://orcid.org/0000-0003-0907-1553
Neal C. Chen
https://orcid.org/0000-0002-8967-9018
Kyle R. Eberlin
https://orcid.org/0000-0003-4427-2588
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Supplementary Materials
Supplemental material, sj-docx-1-han-10.1177_15589447221109635 for Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation by Hannah J. Szapary, Mara Z. Meulendijks, Steven P. Moura, Anamika Veeramani, Barbara Gomez-Eslava, Yannick A. J. Hoftiezer, Neal C. Chen and Kyle R. Eberlin in HAND