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Clinical Features (OBQ18.111) Content is updated monthly with systematic literature reviews and conferences. Copyright 2003 by the American Academy of Family Physicians. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. Joint hyperextension and stress fractures are less common. Tang, Pediatric foot fractures: evaluation and treatment. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. Hand (N Y). This content is owned by the AAFP. Even with proper healing, your foot may be swollen for several months, and it may be hard to find a comfortable shoe. All critical aspects of phalangeal fracture care will be discussed with pertinent case examples. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis. Some metatarsal fractures are stress fractures. Fracture Fixation, Internal Bone Plates Fracture Fixation Bone Nails Fracture Fixation, Intramedullary Bone Screws Bone Wires Range of Motion, Articular Hemiarthroplasty Arthroplasty Casts, Surgical Treatment Outcome Arthroplasty, Replacement Internal Fixators Retrospective Studies Bone Transplantation Reoperation Injury . 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). If the bone is out of place, your toe will appear deformed. Bicondylar proximal phalanx fractures usually are treated with plate fixation. One of the most common foot fractures in children, Open fractures require irrigation & debridement, Nail-bed injuries involving the germinal matrix should be repaired, Displaced intra-articular fractures of the hallux require reduction. The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. The fifth metatarsal is the long bone on the outside of your foot. The proximal phalanx is the phalanx (toe bone) closest to the leg. They most often involve the metatarsals and toes. Toe and forefoot fractures often result from trauma or direct injury to the bone. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. ClinPediatr (Phila), 2011. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. Epidemiology Incidence To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction. Patients with a proximal fifth metatarsal fracture often present after an acute inversion of the foot or ankle. Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. Copyright 2023 Lineage Medical, Inc. All rights reserved. 36(1)p. 60-3. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. Fractures of the toes and forefoot are quite common. 68(12): p. 2413-8. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. Foot Ankle Int, 2015. Avertical Lachman test will show greater laxity compared to the contralateral side. (Left) In this X-ray, a recent stress fracture in the third metatarsal is barely visible (arrow). Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. 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. An AP radiograph is shown in FIgure A. Rotator Cuff and Shoulder Conditioning Program. myAO. Radiographs are shown in Figure A. (SBQ17SE.89) The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. See permissionsforcopyrightquestions and/or permission requests. The proximal phalanx is the toe bone that is closest to the metatarsals. A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. 2017 Oct 01;:1558944717735947. Diagnosis is made with plain radiographs of the foot. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. angel academy current affairs pdf . Started in 1995, this collection now contains 6407 interlinked topic pages divided into a tree of 31 specialty books and 722 chapters. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. (OBQ09.156) A common complication of toe fractures is persistent pain and a decreased tolerance for activity. This topic will review the evaluation and management of toe fractures in adults. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. (OBQ05.209) A fracture of the toe may result from a direct injury, such as dropping a heavy object on the front of your foot, or from accidentally kicking or running into a hard object. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 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). Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. Patients with circulatory compromise require emergency referral. The patient notes worsening pain at the toe-off phase of gait. Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). While celebrating the historic victory, he noticed his finger was deformed and painful. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. Petnehazy, T., et al., Fractures of the hallux in children. In one rural family practice,1 toe fractures comprised 8 percent of 295 fractures diagnosed; in an Air Force family practice residency program,2 they made up 9 percent of 624 fractures treated. Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence. Search dates: February and June 2015. Your doctor will then examine your foot and may compare it to the foot on the opposite side. ORTHO BULLETS Orthopaedic Surgeons & Providers During this time, it may be helpful to wear a wider than normal shoe. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. Diagnosis is made with plain radiographs of the foot. Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. All Rights Reserved. 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. Copyright 2023 Lineage Medical, Inc. All rights reserved. All the bones in the forefoot are designed to work together when you walk. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. If the bone is out of place, your toe will appear deformed. A fractured toe may become swollen, tender, and discolored. 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. (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). Pearls/pitfalls. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Clin J Sport Med, 2001. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Healing time is typically four to six weeks. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. The talus has a head, constricted neck, and body. They typically involve the medial base of the proximal phalanx and usually occur in athletes. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Nondisplaced acute metatarsal shaft fractures generally heal well without complications. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. He undergoes closed reduction and pinning shown in Figure B to correct alignment. It ossifies from one center that appears during the sixth month of intrauterine life. toe phalanx fracture orthobulletsforeign birth registration ireland forum. 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. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. 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). Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. 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. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. At the conclusion of treatment, radiographs should be repeated to document healing. Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for four to six weeks. Lightly wrap your foot in a soft compressive dressing. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. Your doctor will tell you when it is safe to resume activities and return to sports. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. Copyright 2023 American Academy of Family Physicians. (OBQ05.226) There are 3 phalanges in each toe except for the first toe, which usually has only 2. Your foot may become swollen and discolored after a fracture. 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. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. Reduction of fractures in children can usually be accomplished by simple traction and manipulation; open reduction is indicated if a satisfactory alignment is not obtained. Ulnar side of hand. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 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. Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. Copyright 2023 Lineage Medical, Inc. All rights reserved. Author disclosure: No relevant financial affiliations. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. Proximal metaphyseal. Pediatrics, 2006. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. If more than 25% of the joint surface is involved or if the displacement is more than 2 to 3 mm, closed or open reduction is indicated. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Pain is worsened with passive toe extension. Indications. 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. If it does not, rotational deformity should be suspected. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. Radiographs often are required to distinguish these injuries from toe fractures. and C.W. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. Approximately 10% of all fractures occur in the 26 bones of the foot. This information is provided as an educational service and is not intended to serve as medical advice. Abductor, interosseus, and adductor muscles insert at the proximal aspects of each proximal phalanx. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. While many Phalangeal fractures can be treated non-operatively, some do require surgery. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. Taping may be necessary for up to six weeks if healing is slow or pain persists. Surgery is required in the case of an open fracture, when there is significant displacement, or instability after reduction. If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Surgery is not often required. Patients usually present with a painful, swollen, ecchymotic toe with variable deformity and gait disturbance. The proximal phalanx is the toe bone that is closest to the metatarsals. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). MB BULLETS Step 1 For 1st and 2nd Year Med Students. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Foot fractures range widely in severity, prognosis, and treatment. Patients with intra-articular fractures are more likely to develop long-term complications. Distal metaphyseal. 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. 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. (Right) The bones in the angled toe have been manipulated (reduced) back into place. You can rate this topic again in 12 months. Epidemiology Incidence Nail bed injury and neurovascular status should also be assessed. Each metatarsal has the following four parts: Fractures can occur in any part of the metatarsal, but most often occur in the neck or shaft of the bone. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. combination of force and joint positioning causes attenuation or tearing of the plantar capsular-ligamentous complex, tear to capsular-ligamentous-seasmoid complex, tear occurs off the proximal phalanx, not the metatarsal, cartilaginous injury or loose body in hallux MTP joint, articulation between MT and proximal phalanx, abductor hallucis attaches to medial sesamoid, adductor hallucis attaches to lateral sesamoid, attaches to the transverse head of adductor hallucis, flexor tendon sheath and deep transverse intermetatarsal ligament, mechanism of injury consistent with hyper-extension and axial loading of hallux MTP, inability to hyperextend the joint without significant symptoms, comparison of the sesamoid-to-joint distances, often does not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs, negative radiograph with persistent pain, swelling, weak toe push-off, hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture, persistent pain, swelling, weak toe push-off, used to rule out stress fracture of the proximal phalanx, nonoperative modalities indicated in most injuries (Grade I-III), taping not indicated in acute phase due to vascular compromise with swelling, stiff-sole shoe or rocker bottom sole to limit motion, more severe injuries may require walker boot or short leg cast for 2-6 weeks, progressive motion once the injury is stable, headless screw or suture repair of sesamoid fracture, joint synovitis or osteochondral defect often requires debridement or cheilectomy, abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored, immediate post-operative non-weight bearing, treat with cheilectomy versus arthrodesis, depending on severity, Can be a devastating injury to the professional athlete, Posterior Tibial Tendon Insufficiency (PTTI). While many Phalangeal fractures can be treated non-operatively, some do require surgery. This webinar will address key principles in the assessment and management of phalangeal fractures. 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. 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. 21(1): p. 31-4. Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. The next bone is called the proximal phalanx. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. The fractures reviewed in this article are summarized in Table 1. A Jones fracture has a higher risk of nonunion and requires at least six to eight weeks in a short leg nonweight-bearing cast; healing time can be as long as 10 to 12 weeks. 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. Background: The goal of proximal phalangeal fracture management is to allow for fracture healing to occur in acceptable alignment while maintaining gliding motion of the extensor and flexor tendons. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. Surgery may be delayed for several days to allow the swelling in your foot to go down. Minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts (Figure 2) and fractures with less than 10 of dorsoplantar angulation in the absence of other injuries can generally be managed in the same manner as nondisplaced fractures.24,6 Initial management includes immobilization in a posterior splint (Figure 311 ), use of crutches, and avoidance of weight-bearing activities. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. The Ottawa Ankle and Foot Rules should be applied when examining patients with suspected fractures of the proximal fifth metatarsal to help decide whether radiography is needed14 (Figure 815 ). 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.