What is the treatment for an intra-articular minimally displaced proximal phalanx fracture?

Treatment of Intra-articular Minimally Displaced Proximal Phalanx Fracture

Minimally displaced intra-articular proximal phalanx fractures should be treated with functional splinting that allows for protected mobilization rather than rigid immobilization to achieve bone healing and joint mobility simultaneously. 1, 2

Initial Management

• Assessment: Evaluate for:

  • Degree of displacement (minimal displacement defined as <5mm in any plane)
  • Joint stability
  • Articular surface involvement
  • Associated soft tissue injury

• Immobilization Options:

  • For minimally displaced fractures, a custom-molded 2-component thermoplastic splint is preferred 2
  • The splint should immobilize the metacarpophalangeal (MCP) joint while allowing motion of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints
  • Position the MCP joint in 70-90 degrees of flexion (intrinsic plus position) to stabilize the fracture through tension of the extensor mechanism 3

Treatment Protocol

1. Initial Stabilization:

   • Custom splint application with MCP joint immobilized in flexion
   • Buddy taping to adjacent finger for additional support 4

2. Mobilization Schedule:

   • Begin active PIP and DIP joint motion exercises immediately after splinting to prevent stiffness 1, 2
   • Continue protected mobilization for approximately 3-4 weeks 1

3. Follow-up Care:

   • Radiographic follow-up at 3 weeks to assess healing 1
   • Ice application during first 3-5 days for symptomatic relief 1
   • Splint removal at approximately 4-6 weeks based on radiographic evidence of healing 1, 3

4. Rehabilitation:

   • Progressive range of motion exercises after the immobilization period
   • Directed home exercise program
   • Gradual return to activities as healing progresses 1

Surgical Indications

Surgery is indicated when:

• Displacement exceeds 5mm in any plane
• Intra-articular displacement disrupts joint congruity
• Unstable fracture pattern
• Comminuted fractures where closed reduction cannot restore articular surface 1, 5

Outcomes and Complications

• With proper functional treatment, most patients achieve bone healing and full range of motion simultaneously within 6 weeks 2, 3
• Potential complications of excessive immobilization include:
  • Joint stiffness
  • Muscle atrophy
  • Chronic pain
  • Complex regional pain syndrome 1

Important Considerations

• The advantage of functional splinting over rigid immobilization is the ability to achieve bone healing and recovery of motion simultaneously rather than sequentially 2, 3
• Functional treatment helps prevent rotational and axial deformities that can occur with static immobilization 3
• For more complex intra-articular fractures, surgical options include K-wires, screws, plates, or external fixation 5, 6
• Patient compliance with the rehabilitation protocol is crucial for optimal outcomes

This approach balances the need for fracture stabilization with early mobilization, which is particularly important for hand fractures to prevent stiffness and optimize functional outcomes.