Treatment for Displaced Proximal Finger Fracture
For displaced proximal finger fractures, surgical intervention is indicated when there is displacement with an interfragmentary gap >3mm, significant angulation (>10 degrees), malrotation, or involvement of >50% of the articular surface. 1
Initial Assessment and Imaging
- Standard radiographs (3 views: posteroanterior, lateral, and oblique) are essential for initial diagnosis 1
- Upright radiographs are superior for demonstrating the true degree of displacement compared to supine radiographs 1
- CT without contrast is recommended to confirm fracture and assess fragment size if radiographs are equivocal 1
Treatment Algorithm
Conservative Management
Conservative management is appropriate for:
- Fractures with less than 50% joint involvement
- Stable joint
- Minimal displacement (less than 10 degrees angulation) 1, 2
Treatment approach:
- Immobilization with buddy splinting for minimally displaced fractures 2
- Simple arm sling rather than figure-of-eight bandage for immobilization 1
- Duration of immobilization should be limited to reduce complications 1
Surgical Management
Surgical intervention is indicated for:
- Fractures with >50% articular surface involvement
- Unstable joints
- Displacement with interfragmentary gap >3mm
- Significant angulation (>10 degrees)
- Malrotation 1, 2
Surgical options include:
- Open reduction and internal fixation (ORIF) - commonly used for comminuted intraarticular fractures 3
- Percutaneous antegrade pinning - suitable for less complex fractures 4
- Plate fixation - either dorsal or lateral plating (studies show no significant difference in outcomes between these approaches) 5
- External fixation - useful as a distraction apparatus for metacarpophalangeal joint fixation in comminuted cases 3
Post-Treatment Management
Pain Management
- NSAIDs are recommended for pain and inflammation control 1
- Consider multimodal and opioid-sparing protocols when possible 1
Rehabilitation
- Early mobilization after stable surgical fixation is beneficial for optimal outcomes 1
- Directed home exercise program including active motion exercises helps prevent stiffness 1
- Early active motion post-operatively allows patients to return to work earlier (2.5 weeks vs. 9.0 weeks with immobilization) 4
- Regular movement through complete range of motion is crucial for optimal outcomes 1
Potential Complications
- Joint stiffness
- Chronic pain
- Recurrent instability
- Post-traumatic arthritis
- Extensor lag 1
- Hardware-related complications with plate fixation (interference with extensor mechanism, tendon rupture) 3
Follow-up Care
- Regular assessment of wound healing and radiographic union is necessary 1
- Monitor for hardware-related pain or complications 1
- Delayed treatment can lead to poor outcomes; persistent symptoms warrant prompt advanced imaging 1
Special Considerations
- For elderly patients, consider orthogeriatric co-management to improve functional outcomes and reduce mortality 1
- In diabetic patients, close monitoring of skin is needed to prevent pressure points and breakdown 1
- Smoking cessation is advised as it increases nonunion rates and leads to inferior clinical outcomes 1