What is the best treatment for a comminuted fracture of the first proximal phalanx?

Treatment of Comminuted Fractures of the First Proximal Phalanx

For comminuted fractures of the first proximal phalanx, surgical intervention with internal fixation is strongly recommended to optimize outcomes and restore function.

Assessment and Classification

Before determining the optimal treatment approach, proper assessment of the fracture is essential:

• Evaluate the degree of displacement and comminution
• Determine if the fracture involves the articular surface (base or head)
• Assess stability of the fracture pattern
• Consider patient factors (age, activity level, hand dominance)

Treatment Options Based on Fracture Pattern

1. Comminuted Shaft Fractures

• Plate fixation is the preferred treatment for comminuted proximal phalanx shaft fractures 1
• Benefits include:
  • Stable fixation allowing early mobilization
  • Better restoration of alignment
  • Lower risk of malunion or rotational deformity

2. Comminuted Intra-articular Fractures

• Base fractures:

  • External fixation systems (such as the Ichi-Fixator) have shown excellent results for comminuted intra-articular fractures of the base 2
  • Advantages include:
    • Useful as a distraction apparatus for metacarpophalangeal joint fixation
    • Avoids complications associated with plating (tendon interference, plate prominence)
    • Facilitates wound care in open fractures

• Head fractures:

  • For severely comminuted head fractures, novel techniques like volar plate draping (VPD) may be considered when reconstruction is not possible 3
  • Conventional treatment includes K-wire fixation for unicondylar fractures and plate fixation for bicondylar fractures 1

3. Open Comminuted Fractures

• External fixation is particularly valuable for open comminuted fractures 4, 5
• Benefits include:
  • Stabilization while allowing wound management
  • Relatively inexpensive
  • Enables early mobilization
  • Avoids hardware placement at fracture site

Postoperative Management

1. Immobilization period:

   • External fixators or K-wires typically removed at 4-5 weeks 2
   • Plate fixation may allow earlier protected motion

2. Rehabilitation:

   • Begin range of motion exercises after fixator/K-wire removal
   • Progressive strengthening as healing progresses
   • Full recovery may take 3-6 months

Common Pitfalls and Considerations

• Avoid prolonged immobilization which can lead to stiffness and poor functional outcomes
• Monitor for pin tract infections when using external fixation or K-wires
• Be aware of potential complications:
  • Malunion/rotational deformity
  • Joint stiffness
  • Tendon adhesions
  • Hardware prominence with plate fixation
  • Extensor tendon rupture

Special Considerations

• For severely comminuted fractures with joint involvement, accepting a stable ankylosis in a functional position may be preferable to attempting reconstruction in some cases 5
• When treating fractures of the thumb proximal phalanx, special attention should be paid to maintaining proper alignment and rotation due to its critical role in opposition and pinch

The treatment approach should be tailored based on fracture pattern, with plate fixation generally preferred for comminuted shaft fractures, while external fixation shows excellent results for intra-articular and open comminuted fractures.