How should a chip fracture of the ulnar base of the distal interphalangeal (DIP) joint be treated in a 71-year-old with persistent pain and swelling?

Treatment of Chip Fracture at Ulnar Aspect of Base of DIP Joint in 71-Year-Old with Persistent Pain and Swelling

For a 71-year-old with persistent pain and swelling from a chip fracture at the ulnar base of the DIP joint, surgical referral for open reduction and internal fixation should be strongly considered if the fracture involves >30% of the articular surface, demonstrates >2mm displacement, or if there is joint instability or subluxation. 1, 2

Initial Assessment and Imaging

Start with 3-view radiographs (PA, lateral, and oblique) of the affected finger to fully characterize the fracture 3. The oblique views are critical as standard 2-view imaging misses significant phalangeal fractures 3. Key radiographic features to evaluate:

• Articular surface involvement (measure percentage)
• Displacement (>2mm is significant)
• Fragment size (>1/3 articular surface)
• Joint subluxation or dislocation
• Interfragmentary gap (>3mm indicates instability)

If radiographs are equivocal but clinical suspicion remains high given persistent symptoms, CT without contrast can better define the fracture pattern and articular involvement 3.

Treatment Algorithm

Non-Operative Management (Limited Indications)

Non-operative treatment is appropriate only for:

• Fractures involving <30% of articular surface
• Minimal displacement (<2mm)
• No joint subluxation
• Stable joint on examination

Treatment protocol: Splint the DIP joint in 15-30 degrees of flexion for 4-6 weeks, followed by progressive range of motion exercises 4.

Operative Management (Preferred for Most Symptomatic Cases)

Surgical indications (any one of these warrants referral):

• Articular involvement ≥30% 1
• Displacement ≥2mm 1
• Joint subluxation or dislocation 1
• Persistent instability on examination
• Persistent pain and swelling despite conservative management (as in your patient) 2

Surgical technique: The most recent high-quality evidence supports open reduction and internal fixation using a low-profile mini-plate via volar approach 2. This 2025 study demonstrated:

• Mean DIP motion: 0° extension to 71° flexion
• 98.3% total active joint motion recovery
• Excellent Strickland scores in all cases
• Mean Quick DASH score of 3.03 (minimal disability)
• Allows early postoperative joint motion

Alternative technique: Modified Ishiguro extension block technique with closed reduction and pin fixation can be used for fracture-dislocations, achieving pain-free results in 92% and good-to-excellent outcomes in all cases at 15-month follow-up 1.

Critical Considerations for This 71-Year-Old Patient

Age-specific factors:

• At 71, this patient likely has some degree of osteoporosis, which may affect fracture healing and fixation stability
• However, age alone is not a contraindication to surgery if functional demands warrant intervention
• The persistent pain and swelling suggest inadequate initial treatment or fracture instability

Pitfalls to avoid:

• Do not unnecessarily splint the PIP joint - this commonly causes stiffness without benefit 5
• Do not delay surgical referral if operative criteria are met - delayed treatment (>8 days) may compromise outcomes 1
• Do not accept "stiffness is acceptable" in the DIP joint without first attempting anatomic restoration, especially with persistent symptoms 6, 7

Specific Recommendation for Your Patient

Given the persistent pain and swelling, this suggests either:

1. Inadequate initial immobilization
2. Fracture instability requiring surgical fixation
3. Unrecognized articular involvement or displacement

Obtain updated radiographs immediately to reassess fracture position and healing. If any displacement, articular involvement >30%, or continued instability exists, refer to hand surgery for mini-plate fixation 2. The volar mini-plate approach provides rigid fixation allowing early motion, which is critical for preventing DIP joint stiffness in elderly patients.

If radiographs show stable, minimally displaced fracture, consider CT imaging to rule out occult articular involvement that may explain persistent symptoms 3.

Timeline: Surgery should ideally occur within 7-10 days of injury for optimal outcomes 1, 2. If already beyond this window with persistent symptoms, surgical consultation remains appropriate as delayed fixation can still provide benefit.