Treatment of Non-displaced Proximal Phalanx Fractures
Non-displaced proximal phalanx fractures should be treated with conservative functional treatment using a dorsopalmar splint that immobilizes the wrist and metacarpophalangeal joint while allowing active motion of the interphalangeal joints to achieve both bone healing and free mobility simultaneously.
Conservative Management Approach
Splinting Technique
- Apply a custom-molded dorsopalmar splint that:
- Positions the wrist in 30 degrees of dorsiflexion
- Places the metacarpophalangeal (MCP) joint in 70-90 degrees of flexion (intrinsic plus position)
- Leaves the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints free to move 1
- This position creates tension in the extensor aponeurosis, which covers two-thirds of the proximal phalanx, providing firm stabilization of the fracture 1
Rationale for Functional Treatment
- The goal is to achieve bone healing and restore joint mobility simultaneously rather than sequentially 1, 2
- Active exercises of the PIP and DIP joints during healing help:
- Prevent mobility limitations
- Reduce risk of rotational and axial deformities
- Promote earlier return to function 1
Duration of Treatment
- Typically 4-6 weeks of splinting based on radiographic evidence of healing
- The splint can be removed for wound care and radiographic evaluation as needed 2
Assessment and Monitoring
Initial Evaluation
- Thorough physical examination to assess:
- Digital cascade for signs of rotational deformity
- Coronal alignment
- Joint stability and range of motion 3
- Plain radiographs are sufficient to confirm diagnosis and fracture pattern 3
Follow-up Protocol
- Regular radiographic evaluations at 2-week intervals to monitor:
- Maintenance of fracture reduction
- Progressive bone healing
- Early detection of displacement 3
- If displacement occurs during treatment (>2-3mm), consider conversion to surgical management
Special Considerations
Fracture Location and Pattern
- Fractures in the proximal third of the phalanx are most common (51% of cases) 1
- Transverse fractures are the predominant pattern and respond well to conservative management 1
- For unicondylar fractures, early closed reduction is typically successful 4
Outcomes and Prognosis
- Studies show excellent outcomes with functional treatment:
- 100% fracture consolidation rate
- 86% of patients achieve full range of motion by follow-up
- When limitations occur, they typically involve PIP joint extension (up to 20°) 1
When to Consider Surgical Management
Surgery is indicated for:
- Displacement >2-3mm that cannot be reduced closed
- Unstable fractures after reduction
- Rotational deformity
- Intra-articular fractures with significant step-off 4
Surgical options include:
- Closed reduction with percutaneous Kirschner wire fixation for simple patterns
- Open reduction with multiple K-wires or mini-screws for complex or unstable patterns
- Plate fixation for comminuted fractures 4
Common Pitfalls to Avoid
- Prolonged immobilization: Avoid complete immobilization of all joints as this leads to stiffness and poor functional outcomes
- Inadequate follow-up: Regular monitoring is essential to detect and address displacement early
- Missing rotational deformity: Always assess for rotation which can lead to functional impairment if not corrected
- Improper splint position: Failure to position the MCP joint in flexion reduces the stabilizing effect of the extensor mechanism
The evidence strongly supports functional treatment with early motion for non-displaced proximal phalanx fractures, as it provides excellent healing rates while minimizing stiffness and optimizing functional outcomes.