Treatment of Fractured Distal Phalanx of the Thumb
The standard treatment for a fractured distal phalanx of the thumb is removable splinting for minimally displaced fractures, while surgical fixation is indicated for fractures with significant displacement (>3mm), dorsal tilt >10°, or intra-articular involvement. 1
Initial Assessment
- Radiographic evaluation is essential for diagnosis, with at least 2 views recommended for thumb fractures, though adding an oblique projection increases diagnostic yield 2
- Fractures should be classified based on displacement (>3mm considered significant), angulation, and intra-articular involvement 1
- Assessment should include evaluation for associated injuries such as nail bed trauma or tendon involvement 1
Treatment Algorithm
For Minimally Displaced Fractures:
- Removable splinting is the appropriate treatment option 1
- Duration of immobilization typically lasts 3-4 weeks 1
- Radiographic follow-up should be performed at approximately 3 weeks to confirm adequate healing 1
- Active finger motion exercises should be performed following diagnosis to prevent stiffness, which is one of the most functionally disabling adverse effects 3, 1
For Significantly Displaced Fractures:
- Surgical fixation is indicated for fractures with:
- Displacement >3mm
- Dorsal tilt >10°
- Intra-articular involvement with displacement 1
- For "mallet" injuries involving bony avulsion at the extensor mechanism insertion, surgical fixation is indicated when:
- More than one-third of the articular surface is involved
- Palmar displacement of the distal phalanx is present
- Interfragmentary gap is >3mm 2
Follow-up Protocol
- Initial radiographs to confirm diagnosis and fracture pattern 1
- Follow-up radiographs at approximately 3 weeks post-immobilization to assess healing 1
- Final radiographic evaluation at the time of immobilization removal to confirm adequate healing 1
Potential Complications
- Immobilization-related adverse events occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 1
- Joint stiffness is a common complication without proper treatment and rehabilitation 1
- Delayed diagnosis or inadequate treatment may lead to functional impairment 2
Special Considerations
- For open fractures or those with nail bed involvement, appropriate wound care and potential nail bed repair should be performed 1
- In pediatric patients with Salter-Harris fractures of the distal phalanx, anatomical alignment is crucial to reduce complications such as physeal arrest 4
- For complex injuries with significant tissue loss, length preservation techniques should be considered to maintain function 5
Remember that early diagnosis and appropriate treatment are essential to prevent long-term complications and ensure optimal functional outcomes for the patient.