What is the treatment for a proximal phalanx fracture?

Treatment for Proximal Phalanx Fractures

The optimal treatment for proximal phalanx fractures involves a combination of conservative management with functional splinting for stable fractures and surgical fixation for unstable or significantly displaced fractures, with the primary goal of achieving bone healing while maintaining joint mobility simultaneously rather than sequentially.

Initial Assessment and Management

• Proximal phalanx fractures require prompt evaluation through clinical assessment and radiographic imaging to determine fracture pattern, displacement, and stability 1
• Pain management is essential and should include appropriate analgesia while avoiding NSAIDs in patients with renal dysfunction 2

Treatment Algorithm Based on Fracture Type

Conservative Management

• Inherently stable and minimally displaced fractures can be treated non-surgically with functional splinting 1
• The preferred conservative approach includes:
  • Custom-molded thermoplastic splinting that immobilizes the metacarpophalangeal joint while allowing proximal and distal interphalangeal joint motion 3
  • Positioning the hand in an "intrinsic plus" position (wrist dorsiflexed 30 degrees, metacarpophalangeal joints flexed 70-90 degrees) which provides natural splinting of the fracture through the extensor aponeurosis 4
  • Buddy taping to an adjacent finger combined with early mobilization, particularly effective for base fractures of the fifth proximal phalanx 5

Surgical Management

• Surgical intervention is indicated for:

  • Unstable fractures
  • Significantly displaced fractures
  • Fractures with rotational deformity
  • Intra-articular fractures with joint incongruity 1

• Surgical options include:

  • Kirschner wire fixation: Preferred for transverse and short oblique fractures of the proximal phalanx shaft and metacarpal neck fractures 1
  • Plate fixation: Indicated for bicondylar proximal phalanx fractures and comminuted fractures of both the proximal phalanx and metacarpals 1
  • Lag screws: Optimal for spiral long oblique phalanx shaft fractures and metacarpal head fractures 1

Rehabilitation Protocol

• Early protected mobilization is crucial for optimal functional outcomes 3
• Dynamic treatment approaches that allow simultaneous bone healing and joint mobility have shown excellent results with:
  • 86% of patients achieving full range of motion 4
  • 72% excellent and 22% good outcomes using Total Active Motion Scores 6
• Traction splints can effectively utilize the stabilizing effect of soft tissues (Zancolli complex-metacarpophalangeal retention apparatus) while allowing controlled movement 6

Potential Complications and Monitoring

• Common complications to monitor for include:

  • Limitation of extension at the proximal interphalangeal joint (up to 20 degrees in some cases) 4
  • Malrotation (occurring in approximately 5.7% of conservatively managed fractures) 5
  • Decreased mobility despite exact fracture reduction with internal fixation 5

• Follow-up should include:

  • Regular radiographic assessment to ensure proper bone healing
  • Monitoring of joint mobility and function
  • Assessment for rotational or axial deformities 4

Special Considerations

• The goal of treatment should be to achieve bony healing and free mobility simultaneously rather than sequentially 4, 3
• Functional outcomes often take priority over perfect anatomical reduction, particularly in the fifth digit 5
• Custom-molded splints offer the advantage of being removable for wound care and radiographic evaluations while maintaining fracture stability 3