What is the initial management for a Salter-Harris II fracture involving the proximal metaphysis of the proximal phalanx of the right fifth finger?

From the Guidelines

The initial management for a Salter-Harris II fracture involving the proximal metaphysis of the proximal phalanx of the right fifth finger involves closed reduction followed by immobilization, as this approach prioritizes minimizing morbidity, mortality, and optimizing quality of life by promoting proper healing and reducing the risk of complications.

Initial Management Steps

• Perform digital or wrist block anesthesia using 1-2% lidocaine without epinephrine (3-5 mL) to ensure adequate pain control during the reduction process, as recommended by general medical practice for such procedures 1.
• Apply gentle longitudinal traction to disengage the fracture fragments, then manipulate the distal fragment to align with the proximal fragment, taking care to avoid further injury to the surrounding tissues.
• Once reduced, immobilize the finger with an ulnar gutter splint or buddy taping to the adjacent fourth finger for 3-4 weeks, allowing for proper healing while maintaining some degree of mobility to prevent stiffness.
• The metacarpophalangeal (MCP) joint should be flexed at 70-90 degrees while the proximal interphalangeal (PIP) joint is slightly flexed to prevent stiffness and maintain collateral ligament length, which is crucial for the functional recovery of the finger.
• Elevate the hand above heart level and apply ice intermittently for the first 48 hours to reduce swelling, following the principles of reducing inflammation and promoting healing.
• Prescribe appropriate analgesics such as acetaminophen 500-1000 mg every 6 hours or ibuprofen 400-600 mg every 6-8 hours for pain control, ensuring the patient's comfort and adherence to the treatment plan.
• Arrange follow-up within 5-7 days with repeat radiographs to confirm maintained reduction, which is essential for monitoring the healing process and making any necessary adjustments to the treatment plan, as suggested by the approach to managing acute hand and wrist trauma 1.

Rationale

This approach is based on the understanding that Salter-Harris II fractures, by definition, involve the growth plate and a portion of the metaphysis, and thus have a relatively good prognosis for healing when managed appropriately. The thick periosteum that remains intact on one side of the fracture provides stability and a blood supply for healing, which supports the use of closed reduction and immobilization as the initial management strategy. Furthermore, the guidelines for acute hand and wrist trauma emphasize the importance of initial radiographs for detecting fractures and guiding further management, which aligns with the recommended approach for this specific type of fracture 1.

From the Research

Initial Management of Salter-Harris II Fracture

The initial management of a Salter-Harris II fracture involving the proximal metaphysis of the proximal phalanx of the right fifth finger can be approached in the following ways:

• Nondisplaced fractures can be managed with splint immobilization 2
• Stable, reduced fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction 2
• Unstable, displaced fractures require surgical management, preferably via closed reduction and percutaneous pinning 2

Considerations for Treatment

When treating a proximal phalangeal base fracture in children, the possibility of flexor tendon entrapment should be considered and carefully dealt with in its treatment 3

• A thorough physical examination is necessary to assess the digital cascade for signs of rotational deformity and/or coronal malalignment 2
• Plain radiographs of the hand and digits are sufficient to confirm a diagnosis of a phalangeal fracture 2

Specific Treatment Approaches

• Conservative management with splintage can be effective for some cases, as seen in a case report of a Salter-Harris type 2 physeal injury involving the proximal phalanx of the great toe 4
• Surgical management may involve removal of volarly displaced metaphyses, freeing of entrapped tendons, and anatomical fixation with K-wires, as described in a case report of a Salter-Harris type II fracture of the proximal phalanx of the fifth finger 3
• Chiropractors may consider radiography of post-traumatic injury sites even with equivocal examination findings, as seen in a case report of a Salter-Harris type II fracture of the proximal phalanx of the second toe 5