What is the treatment for a middle phalanx fracture?

Treatment of Middle Phalanx Fractures

The treatment of middle phalanx fractures depends primarily on fracture stability, displacement, and articular involvement, with most stable fractures being successfully managed non-operatively while unstable or displaced fractures often require surgical intervention. 1

Classification and Assessment

• Middle phalanx fractures can be classified into five types: single palmar fragment, single dorsal fragment, two main fragments, non-articular (including epiphyseal separations in children), and complex fractures 2
• Look for obvious deformity, swelling, bruising, severe pain with movement, or inability to move the affected digit 3
• Radiographic assessment should ideally be performed with upright radiographs as they better demonstrate the degree of displacement compared to supine radiographs 4

Non-operative Treatment

• Non-surgical management is the preferred treatment for stable, non-displaced extra-articular fractures of the middle phalanx 5
• Immobilization options include:
  • Rigid immobilization with splinting is preferred over removable splints for displaced fractures 4
  • Splinting should be used rather than figure-of-eight bracing (based on expert opinion for clavicle fractures, which can be applied to phalangeal fractures) 4
• Duration of immobilization typically ranges from 3-4 weeks depending on fracture stability and healing progress 1

Surgical Treatment

• Surgery is indicated for:
  • Unstable fractures
  • Displaced articular fractures
  • Open fractures
  • Multiple fractures
  • Fractures with associated soft tissue injuries 1, 5
• Surgical options include:
  • Closed reduction with percutaneous pinning for unstable but reducible fractures 5
  • Open reduction with internal fixation (ORIF) using plates or screws for severely displaced or comminuted fractures 5
  • Headless compression screws for unicondylar fractures, especially in high-demand patients 5
  • Dynamic external fixation devices like the Ligamentotaxor® for intra-articular fractures (showing good functional outcomes with mean flexion of 73° and extension deficit of 13° at 15 months) 6

Special Considerations

• For fracture-dislocations of the middle phalanx at the proximal interphalangeal joint, intradigital traction devices may be used to avoid open surgery while promoting articular cartilage remodeling through early motion 7
• Unstable type-1 avulsion fractures, type-2 avulsions at risk of buttonhole deformities, and all fractures with displaced articular surfaces should be surgically treated 2
• Careful soft tissue handling and early mobilization are fundamental principles of surgical phalangeal fracture treatment 1

Rehabilitation

• Early mobilization should be initiated as soon as fracture stability allows to prevent stiffness 1
• Rehabilitation should include:
  • Muscle strengthening exercises 3
  • Long-term continuation of hand exercises 3
  • Patient education about pain management strategies 3
  • Patient education about rehabilitation exercises 3
  • Monitoring for signs of complications requiring medical attention 3

Outcomes

• Long-term follow-up shows that surgical treatment which achieves good stability and articular congruity provides good functional results 2
• Elite athletes with stable fractures may return to play earlier with protective splinting, while those requiring ORIF with plate fixation can benefit from rigid fixation allowing immediate range of motion 5