What is the management for a comminuted fracture of the proximal phalanx of the right third digit?

Management of Comminuted Fracture of the Proximal Phalanx of the Right Third Digit

For comminuted fractures of the proximal phalanx of the right third digit, functional treatment with early mobilization is strongly recommended over static immobilization to achieve both bone healing and free mobility simultaneously.

Assessment and Initial Management

• Obtain proper radiographic imaging to assess fracture pattern, displacement, and articular involvement
• Provide appropriate analgesia:
  • Regular acetaminophen/paracetamol as primary treatment 1
  • Careful use of opioids, especially in patients with renal dysfunction 1
  • Consider multimodal analgesia approach to limit opioid use 1

Treatment Options

Conservative Management

1. Functional treatment with dynamic splinting (preferred for most cases):

   • Dorsopalmar plaster splint with the wrist in 30° dorsiflexion
   • Metacarpophalangeal (MCP) joint positioned in 70-90° flexion (intrinsic plus position)
   • This position creates natural splinting of the fracture as the extensor aponeurosis covers two-thirds of the proximal phalanx 2
   • Allow active exercises of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints while the fracture is stabilized

2. Traction splinting:

   • Utilizes the stabilizing effect of soft tissues (Zancolli complex-metacarpophalangeal retention apparatus)
   • Enables simultaneous bone healing and movement recovery
   • Studies show excellent results in 72% of patients and good results in 22% 3

3. Buddy taping:

   • After initial closed reduction if needed
   • Tape the injured finger to an adjacent digit (typically the ring finger)
   • Allows for immediate mobilization 4
   • Most effective for minimally displaced fractures

Surgical Management

Reserved for:

• Unstable fractures
• Significantly displaced fractures
• Intra-articular comminuted fractures, especially involving the base of the proximal phalanx

Surgical options include:

1. Open reduction and internal fixation (ORIF):

   • K-wires for fixation
   • May be combined with external fixation for additional stability 5

2. External fixation:

   • Particularly useful for comminuted intra-articular fractures
   • Provides distraction and stabilization while allowing early range of motion
   • The Ichi-Fixator system has shown success in treating comminuted intra-articular fractures of the base of the proximal phalanx 5

Rehabilitation Protocol

1. Early mobilization:

   • Begin active range of motion exercises as soon as stability allows
   • For conservative treatment: immediate active PIP and DIP joint movement
   • For surgical cases: typically begin 4-5 weeks post-operatively 5

2. Progressive rehabilitation:

   • Gradually increase range of motion exercises
   • Add strengthening exercises as healing progresses
   • Monitor for complications such as stiffness, malrotation, or non-union

Expected Outcomes

• Full consolidation can be expected in most cases
• Studies show excellent functional outcomes with dynamic treatment approaches:
  • 86% of patients achieve full range of motion 2
  • Only 14% show limitation of finger joint movements 2
• No delayed fracture healing or pseudarthrosis observed with appropriate management 2

Potential Complications to Monitor

• Limitation of extension of the PIP joint (most common)
• Limitation of flexion (less common)
• Malrotation
• Joint stiffness
• Delayed union or non-union (rare with appropriate treatment)

Follow-up

• Regular radiographic assessment to monitor fracture healing
• Clinical evaluation of range of motion, grip strength, and functional recovery
• Adjust rehabilitation protocol based on progress

The functional treatment approach focusing on early mobilization has demonstrated superior outcomes compared to static immobilization, as it prevents the development of joint stiffness while still allowing for proper bone healing.