What is the management for a pediatric fifth finger fracture?

Management of Pediatric Fifth Finger Fractures

Most pediatric fifth finger fractures can be managed conservatively with appropriate immobilization, with surgical intervention reserved only for unstable, significantly displaced, or intra-articular fractures. 1, 2, 3

Assessment and Classification

• Evaluate for:
  • Fracture location (proximal, middle, or distal phalanx)
  • Displacement and angulation
  • Rotation (check finger alignment when partially flexed)
  • Open vs. closed fracture
  • Associated soft tissue injuries (particularly nail bed injuries with distal fractures)
  • Growth plate involvement (Salter-Harris classification if applicable)

Treatment Algorithm

1. Undisplaced or Minimally Displaced Fractures

• First-line treatment: Conservative management with immobilization 2, 3, 4
  • Buddy taping to adjacent finger for stable fractures
  • Removable splint for slightly unstable fractures
  • Custom-molded splint or cast for more unstable patterns
• Immobilization period: 3-4 weeks maximum 5
  • Avoid immobilizing for longer than 4 weeks to prevent stiffness 3

2. Displaced Fractures

• Attempt gentle closed reduction for:
  • Angular deformity >10-15 degrees
  • Any rotational deformity (no tolerance for rotation)
  • Significant displacement
• After reduction, immobilize with splint or cast 4
  • Recent evidence shows no significant difference in outcomes between splinting and casting 4
  • Splinting offers better comfort and hygiene

3. Indications for Surgical Management

• Failed closed reduction
• Unstable fractures
• Intra-articular fractures with significant displacement
• Malrotated fractures that cannot be reduced
• Open fractures with significant soft tissue injury

Special Considerations

Age-Specific Patterns

• Young children (infants/preschoolers):

  • Often crush injuries (e.g., door slams)
  • Distal phalanx injuries most common
  • Associated nail bed injuries requiring repair 2, 6

• Older children/adolescents:

  • Sports-related injuries more common
  • Proximal phalanx fractures of the fifth finger predominate 6, 5

Growth Plate Considerations

• Approximately 19% of pediatric hand fractures involve growth plate injuries 6
• Salter-Harris type I and II injuries generally heal well with conservative management
• Salter-Harris type III and IV injuries may require surgical intervention to restore articular congruity

Follow-up Protocol

• Initial follow-up at 7-10 days to ensure maintenance of reduction
• Radiographic follow-up at 3-4 weeks to assess healing
• Consider earlier mobilization for stable fractures to prevent stiffness
• Minimize unnecessary imaging that won't change management 7

Common Pitfalls to Avoid

1. Missing rotational deformity: Always check for rotation by having the child partially flex fingers
2. Over-immobilization: Avoid immobilizing for more than 4 weeks to prevent stiffness
3. Inadequate reduction: No tolerance for rotational malalignment as it doesn't remodel
4. Overlooking associated injuries: Particularly nail bed injuries with distal phalanx fractures
5. Failing to recognize fractures requiring surgery: Intra-articular fractures, displaced phalangeal neck fractures, and malrotated fractures typically need surgical intervention 2

While most pediatric fifth finger fractures can be managed conservatively with excellent outcomes, careful assessment for rotational deformity and proper immobilization technique are essential to prevent long-term functional impairment.