What are the treatment guidelines for a non-displaced angulated fracture of the proximal phalange?

Treatment Guidelines for Non-Displaced Angulated Fracture of the Proximal Phalanx

Non-displaced angulated fractures of the proximal phalanx should be treated conservatively with splinting in the intrinsic plus position, followed by early controlled mobilization, unless the angulation exceeds 25° in the sagittal plane or 10° in the coronal plane. 1

Initial Assessment and Immobilization

When evaluating a non-displaced angulated proximal phalanx fracture, consider:

• Degree of angulation (acceptable if <25° in sagittal plane, <10° in coronal plane)
• Presence of rotation (any rotational deformity is unacceptable)
• Stability of the fracture

The recommended immobilization technique involves:

1. A dorsopalmar splint with the wrist in 30° dorsiflexion
2. Metacarpophalangeal (MCP) joints flexed at 70-90° (intrinsic plus position)
3. Proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints free to move 2

This position takes advantage of the extensor aponeurosis, which becomes taut and covers two-thirds of the proximal phalanx, providing natural splinting of the fracture 2.

Treatment Algorithm

For Stable Non-Displaced Angulated Fractures:

1. Apply dorsopalmar splint in intrinsic plus position
2. Begin immediate active PIP and DIP joint exercises
3. Maintain splint for 3-4 weeks
4. Follow up with radiographs to ensure maintenance of reduction

For Initially Unstable Fractures:

1. Perform closed reduction
2. Apply dorsopalmar splint in intrinsic plus position
3. If reduction is maintained and stable, continue with conservative management
4. If reduction cannot be maintained or angulation exceeds acceptable limits, proceed to surgical fixation (typically with K-wires) 3

Mobilization Protocol

Early controlled mobilization is crucial for optimal outcomes:

• Begin active PIP and DIP joint exercises immediately while the MCP joint remains immobilized
• This prevents stiffness and edema while promoting healing 2, 1
• After 3-4 weeks, begin weaning from the splint
• Implement a home exercise program focusing on active and passive range of motion exercises 4

Expected Outcomes

With appropriate conservative management, patients can expect:

• Complete bony union in virtually all cases
• Good functional outcomes with minimal pain
• Median PIP joint extension of -4° and mean total active motion of 253° 1
• Return to full activities within 6-8 weeks

Indications for Surgical Management

Consider surgical intervention (typically closed reduction with percutaneous pinning or open reduction with internal fixation) when:

• Angulation exceeds 25° in sagittal plane or 10° in coronal plane after attempted reduction
• Rotational deformity is present
• Fracture is unstable and cannot maintain reduction
• Intra-articular involvement 3

Monitoring and Follow-up

1. Regular radiographic assessment to ensure maintenance of reduction
2. Monitor for complications such as:
   • Joint stiffness
   • Malunion
   • Rotational deformity
   • Extensor lag

Special Considerations

For pediatric patients, Salter-Harris type II fractures of the proximal phalanx are most common. These fractures are typically more stable after reduction than adult fractures and have excellent healing potential 5.

For elderly patients or those with osteoporosis, consider:

• Longer immobilization period (4-5 weeks)
• Calcium and vitamin D supplementation
• Careful monitoring for skin breakdown under splint

The American Heart Association and American Red Cross guidelines (2024) emphasize that splinting of fractured extremities is useful to reduce pain, reduce risk for further injury, and facilitate transport to a medical facility 6. They also recommend treating deformed fractured extremities in the position found unless straightening is necessary for safe transport 6.