What is the recommended management for a 14-year-old (YO) patient with an acute nondisplaced small intra-articular fracture on the volar aspect of the base of the left fifth middle phalanx?

Management of Acute Nondisplaced Small Intra-articular Fracture of the Base of Left Fifth Middle Phalanx in a 14-Year-Old

For a 14-year-old with an acute nondisplaced small intra-articular fracture on the volar aspect of the base of the left fifth middle phalanx, conservative management with rigid immobilization and early active finger motion exercises is the recommended approach to optimize functional outcomes.

Initial Management

Immobilization

• Apply rigid immobilization (cast or splint) to stabilize the fracture while maintaining the finger in a functional position
• Immobilize the proximal interphalangeal (PIP) joint while allowing distal interphalangeal (DIP) joint motion
• Immobilization period typically 3-4 weeks for nondisplaced intra-articular fractures

Early Motion Protocol

• Begin active finger motion exercises immediately following diagnosis to prevent stiffness 1
• Instruct the patient to perform regular range of motion exercises through a complete range of motion while maintaining the immobilization
• This is an extremely cost-effective intervention that significantly impacts patient outcomes by preventing finger stiffness, which is one of the most functionally disabling complications 1

Radiographic Follow-up

• Obtain follow-up radiographs at approximately 3 weeks and at cessation of immobilization to ensure proper healing and alignment 2
• No need for excessive radiographic follow-up as evidence suggests no difference in outcomes based on frequency of radiographic evaluation 1
• Consider CT scan only if there is concern about fracture displacement or complex fracture patterns during follow-up 1

Rehabilitation Phase

• After immobilization period (3-4 weeks), begin progressive rehabilitation:
  • Range of motion exercises
  • Strengthening exercises
  • Gradual return to normal activities

Surgical Considerations

• Surgery is generally not indicated for nondisplaced small intra-articular fractures 3
• Surgical intervention would only be considered if:
  • Fracture displaces during follow-up
  • Joint incongruity develops
  • Loss of reduction occurs

Pain Management

• Use multimodal and opioid-sparing protocols when possible 1
• Consider:
  • NSAIDs (if no contraindications)
  • Acetaminophen
  • Ice for pain and swelling control

Prognosis and Expected Outcomes

• Prognosis is generally good for nondisplaced intra-articular fractures with appropriate management
• Some residual stiffness may occur despite optimal management
• Return to full activities typically within 6-8 weeks

Potential Complications to Monitor

• Finger stiffness (most common complication)
• Malunion
• Post-traumatic arthritis
• Growth plate concerns (given patient's age)

Key Points for Success

• Early finger motion is critical to prevent stiffness while maintaining adequate immobilization 1
• Patient education and compliance with home exercise program is essential
• Regular follow-up to ensure proper healing and alignment
• Prompt recognition and management of any complications