What is the treatment for a fracture at the base of the fifth middle phalanx with intra-articular extension?

Treatment of Fracture at the Base of the Fifth Middle Phalanx with Intra-articular Extension

Surgical fixation is recommended for fractures at the base of the fifth middle phalanx with intra-articular extension, as these fractures require restoration of joint congruity to prevent post-traumatic arthritis and functional impairment. 1

Initial Assessment

• Standard 3-view radiographic examination (PA, lateral, and oblique views) is the initial imaging modality of choice for suspected 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 IV contrast may be necessary when radiographs are equivocal to better evaluate intra-articular extension and displacement 2

Treatment Decision Algorithm

Surgical Indications

• Intra-articular extension with displacement >3mm or articular step-off 1
• Fractures involving more than one-third of the articular surface 2
• Interfragmentary gap >3mm 2
• Joint instability or incongruity 1

Surgical Options

1. Dynamic External Fixation

   • Preferred for unstable intra-articular fractures of the middle phalanx 1
   • Suzuki dynamic fixator using K-wires and rubber bands allows for early mobilization while maintaining reduction 3
   • Average duration of external fixation is approximately 28 days 3

2. Open Reduction and Internal Fixation (ORIF)

   • Options include K-wire fixation, miniplate fixation, or screws 4, 5
   • Volar plating approach offers direct visualization of fracture fragments and allows for accurate reduction of articular surface 4
   • Miniplate fixation provides rigid stability and allows for early finger joint motion 5

3. Arthroscopic-Assisted Reduction

   • Useful for improved diagnostic accuracy and treatment of intra-articular fractures 1
   • Allows for evaluation and treatment of associated ligament injuries 1

Post-Operative Management

• Early active motion exercises should be initiated as soon as stability allows to prevent stiffness 1
• For external fixation techniques, active exercises can begin on the day of surgery 3
• Radiographic follow-up at approximately 3 weeks and at the time of hardware removal to confirm adequate healing 1

Expected Outcomes and Complications

• With dynamic external fixation, average range of motion of 64° can be expected, with most patients achieving pain-free function 3
• Joint stiffness is one of the most functionally disabling complications and can be minimized with early appropriate motion 1
• Immobilization-related complications occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 1
• Without proper treatment, intra-articular fractures can lead to joint incongruity and subsequent arthritis 1

Pitfalls to Avoid

• Avoid conservative management with simple splinting for displaced intra-articular fractures, as this leads to poor outcomes and post-traumatic arthritis 1
• Avoid excessive immobilization, as this increases the risk of stiffness 1
• When using plate fixation, careful placement is necessary to prevent interference with tendon excursion 4
• Ensure anatomic reduction of the articular surface with <2mm of residual step-off to minimize long-term complications 6