What is the treatment for a mildly displaced oblique intra-articular avulsion type fracture off the dorsal base of the right 3rd distal phalanx?

Treatment for Mildly Displaced Oblique Intra-articular Avulsion Fracture of the Dorsal Base of the Right 3rd Distal Phalanx

Conservative management with immobilization is the recommended first-line treatment for mildly displaced intra-articular avulsion fractures of the dorsal base of the distal phalanx. 1

Assessment and Diagnosis

• Obtain standard radiographs (posteroanterior, lateral, and oblique views) for initial diagnosis 1
• Consider CT without contrast if radiographs are equivocal but clinical suspicion remains high 1
• Evaluate for:
  • Percentage of joint involvement
  • Degree of displacement (measure interfragmentary gap)
  • Joint stability
  • Angulation

Treatment Algorithm

Conservative Management (First-Line)

For fractures with:

• Less than 50% joint involvement
• Minimal displacement (less than 3mm gap)
• Stable joint
• Minimal angulation (less than 10 degrees)

Treatment consists of:

1. Immobilization with splinting
2. NSAIDs for pain and inflammation control 1
3. Early directed home exercise program to prevent stiffness 1
4. Limiting duration of immobilization to reduce complications 1

The classic teaching from earlier literature supports this approach, noting that dorsal articular fractures (mallet fractures) can and should be treated by nonoperative means 2.

Surgical Management (Second-Line)

Consider surgery if:

• Fracture involves more than 50% of the articular surface
• Unstable joint
• Displacement with interfragmentary gap >3mm
• Significant angulation (>10 degrees)
• Malrotation 1

Surgical options include:

1. Open reduction and internal fixation with Kirschner wires 3

   • Historical data shows excellent outcomes with this approach for fractures involving one-third or more of the articular surface
   • Average loss of extension was only 2 degrees with an average arc of flexion of 69 degrees

2. Extra-articular DIP pinning 4

   • More recent technique using two connected K-wires
   • One wire placed inside the shaft of the distal phalanx, the other perpendicular to the middle phalanx
   • K-wires typically removed after 1 month
   • Provides stable fixation while avoiding complications of intra-articular pinning

Rehabilitation and Follow-up

• Early mobilization after stable fixation is beneficial for optimal outcomes 1
• Implement a directed home exercise program including active motion exercises 1
• Monitor for complications:
  • Joint stiffness
  • Chronic pain
  • Post-traumatic arthritis
  • Extensor lag 1

Important Considerations

• Delayed treatment can lead to poor outcomes 1
• Persistent symptoms warrant prompt advanced imaging rather than prolonged observation 1
• For elderly patients, evaluate for osteoporosis risk factors and consider calcium and vitamin D supplementation 1
• Advise smoking cessation as it increases nonunion rates and leads to inferior clinical outcomes 1

The most recent evidence suggests that conservative management with appropriate immobilization and early mobilization provides excellent outcomes for mildly displaced dorsal avulsion fractures of the distal phalanx, with surgical intervention reserved for more complex or unstable cases.