What is the treatment for a mildly displaced fracture at the distal aspect of the 4th digit with intraarticular extension at the Proximal Interphalangeal (PIP) joint?

Treatment of Mildly Displaced Fracture at the Distal Aspect of the 4th Digit with Intraarticular Extension at the PIP Joint

For a mildly displaced fracture at the distal aspect of the 4th digit with intraarticular extension at the PIP joint, surgical fixation is recommended to restore joint congruity and allow for early mobilization. 1, 2

Assessment and Classification

• Intraarticular fractures with displacement require careful evaluation of the degree of displacement, joint congruity, and stability to determine the optimal treatment approach 3
• Fractures are classified as significantly displaced when there is >3mm displacement or >10° dorsal tilt 3
• The presence of intraarticular extension is a critical factor that influences treatment decisions, as it can lead to joint incongruity and subsequent arthritis if not properly addressed 4

Treatment Options

Surgical Management

• For intraarticular fractures with displacement at the PIP joint, surgical intervention is indicated to restore joint congruity and prevent long-term complications 1
• Several surgical options are available based on fracture pattern and stability:

1. Open Reduction and Internal Fixation (ORIF)

   • Indicated for unstable fractures with articular involvement
   • Provides direct visualization and anatomic reduction of the fracture fragments
   • Average post-operative range of motion of 84.7° at final follow-up 1
   • Allows for interfragmentary screw fixation which provides stable fixation for early mobilization 2

2. Percutaneous Fixation

   • Yields the highest post-operative range of motion (86.5°) at final follow-up among surgical techniques 1
   • Less invasive than open approaches with potentially less soft tissue disruption 1

3. Dynamic External Fixation (Pins and Rubber Traction System)

   • Effective for unstable intraarticular fractures
   • Allows for early mobilization while maintaining reduction
   • Average post-operative range of motion of 81.7° 1
   • Provides distraction to maintain joint space while allowing controlled motion 5

4. Arthroscopic-Assisted Reduction

   • Option for improved diagnostic accuracy and treatment of intraarticular fractures 4
   • Allows for evaluation and treatment of associated ligament injuries 6
   • Minimizes capsular and soft tissue scarring, potentially improving functional outcomes 7

Conservative Management

• Not typically recommended for intraarticular fractures with displacement due to risk of joint incongruity and subsequent arthritis 3
• Removable splints may be appropriate only for minimally displaced fractures without significant intraarticular involvement 8

Post-Operative Management

• Active finger motion exercises should be initiated as soon as stability allows to prevent stiffness 8, 3
• Radiographic follow-up is recommended at approximately 3 weeks and at the time of immobilization removal to confirm adequate healing 8
• Early mobilization is crucial to optimize functional outcomes and prevent joint stiffness 1, 2

Potential Complications

• Joint stiffness is one of the most functionally disabling adverse effects of finger fractures and can be minimized with early appropriate motion 8
• Immobilization-related complications occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 3
• Post-traumatic arthritis can develop if joint congruity is not restored, particularly with intraarticular fractures 1

Prognostic Factors

• The quality of articular reduction directly correlates with long-term outcomes and development of post-traumatic arthritis 1
• Dorsal fracture-dislocations generally have better outcomes (average ROM 83.2°, QuickDASH 6.6) compared to pilon injuries (average ROM 80.2°, QuickDASH 11.4) 1
• Early motion protocols improve functional outcomes when fracture stability is achieved 2