What is the treatment for an acute nondisplaced articular fracture at the base of the middle phalanx communicating with the Proximal Interphalangeal (PIP) joint of the small finger?

Treatment of Acute Nondisplaced Articular Fracture at the Base of Middle Phalanx Communicating with PIP Joint Small Finger

Conservative management with immobilization is indicated for this nondisplaced articular fracture at the base of the middle phalanx, as it has minimal displacement and involves the PIP joint of the small finger. 1

Initial Assessment and Imaging

• Standard radiographs (3 views: posteroanterior, lateral, and oblique) are essential for proper evaluation of phalangeal fractures 2
• An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 2
• CT without contrast may be considered if radiographs are equivocal but clinical suspicion remains high 2, 1

Treatment Algorithm

For Nondisplaced Fractures (Current Case)

1. Conservative management with immobilization is the first-line treatment when:

   • The fracture is nondisplaced
   • Joint stability is maintained
   • Less than 35% of the articular surface is involved 3

2. Immobilization options:

   • Extension block splinting in 20-30° of flexion for 3-4 weeks
   • Buddy taping to adjacent finger
   • Early protected motion protocols to prevent stiffness 1

3. Follow-up:

   • Radiographic reassessment at 7-10 days to ensure fracture remains nondisplaced
   • Early finger motion exercises to prevent stiffness 1

When Surgical Intervention Is Needed

Surgical treatment would be indicated if:

• Fracture involves >35% of the articular surface 3
• Relative fracture displacement >35% 3
• Joint subluxation or instability is present
• Secondary displacement occurs during follow-up

Rehabilitation Protocol

1. Early finger motion is essential to prevent edema and stiffness 1
2. Directed home exercise program can be as effective as supervised therapy 1
3. Progressive strengthening once fracture healing is confirmed

Potential Complications and Prevention

• Joint stiffness is the most common complication
• Post-traumatic arthritis may develop if articular congruity is not maintained
• Regular assessment of healing and joint stability is necessary 1

Evidence Quality and Considerations

The treatment approach is supported by guidelines from the American College of Radiology 2 and recommendations summarized in Praxis Medical Insights 1. Recent research by Hand (New York, N.Y.) in 2022 3 provides specific thresholds for determining stability, noting that fractures with less than 35% articular involvement and less than 35% displacement typically maintain joint stability.

While some studies have explored various surgical techniques for unstable PIP joint fractures 4, 5, these are not indicated for the nondisplaced fracture described in this case. The most recent evidence from 2024 5 describes internal joint stabilizers for unstable fractures, but this would be reserved for cases with demonstrated instability.

It's important to note that even with appropriate treatment, patients may not regain full mobility of the PIP joint 6, making early motion protocols particularly important to maximize functional outcomes.