What is the management approach for a distal phalanx avulsion fracture?

Management of Distal Phalanx Avulsion Fracture

Distal phalanx avulsion fractures should be managed based on fracture characteristics, with conservative treatment indicated for stable fractures with minimal displacement (<10 degrees angulation) and less than 50% joint involvement, while surgical intervention is recommended for unstable or significantly displaced fractures.

Assessment and Classification

When evaluating a distal phalanx avulsion fracture, consider:

• Initial evaluation should include standard radiographs (anteroposterior, lateral, and mortise views) to assess fracture pattern and displacement 1
• CT without contrast may be recommended if radiographs are equivocal but clinical suspicion remains high 1
• Determine if the fracture involves the flexor digitorum profundus (FDP) insertion, extensor tendon insertion, or both 2, 3
• Assess for associated injuries such as tendon avulsion, joint subluxation, or rotational deformity 4

Conservative Management

Conservative treatment is appropriate for:

• Fractures with less than 50% joint involvement
• Stable fractures with minimal displacement (<10 degrees angulation)
• No evidence of joint subluxation or significant rotational deformity 1, 4

The conservative approach includes:

• Immobilization with a dorsopalmar splint that maintains the wrist in 30 degrees dorsiflexion and metacarpophalangeal joints in 70-90 degrees flexion (intrinsic plus position) 5
• Early finger motion exercises to prevent stiffness and edema 1
• Regular assessment of wound healing and radiographic union 1
• A directed home exercise program that can be as effective as supervised therapy 1

Surgical Management

Surgical intervention is indicated for:

• Unstable fractures
• Significant displacement
• Intra-articular fractures with joint subluxation
• Rotational malposition of the bony fragment 1, 4

Surgical techniques include:

• Open reduction and internal fixation (ORIF) with direct visualization of fracture fragments 1
• Fixation with small screws (e.g., 1.5 mm) for larger fragments 3
• Anatomical reduction of fracture fragments with fluoroscopic verification 1
• Repair of associated tendon injuries when present 2, 3

Rehabilitation Protocol

Regardless of treatment approach:

• Early finger motion is essential to prevent edema and stiffness 1
• Aggressive finger and hand motion becomes necessary when immobilization is discontinued 1
• Manual joint mobilization combined with exercise therapy may improve outcomes, especially with thumb injuries 1
• Monitor for complications such as joint stiffness, chronic pain, post-traumatic arthritis, and extensor lag 1

Special Considerations

• Uncommon patterns may exist, such as simultaneous dorsal base fracture with FDP avulsion, which may require modified treatment approaches 2, 3
• In skeletally immature patients, stress fractures of the distal phalanx may respond well to conservative treatment alone 6
• NSAIDs are recommended for pain and inflammation control 1
• Smoking cessation is advised as it increases nonunion rates and leads to inferior clinical outcomes 1

Potential Complications

• Joint stiffness and limitation of motion (most common)
• Chronic pain
• Post-traumatic arthritis
• Extensor lag
• Delayed union or nonunion (though rare with appropriate treatment) 1, 5

Regular follow-up with radiographic assessment is crucial to monitor healing and detect complications early.