What is the treatment for a displaced fracture of the dorsum of the base of the middle phalanx of the fourth finger with articular surface involvement?

Treatment for a Displaced Fracture of the Dorsum of the Base of the Middle Phalanx with Articular Surface Involvement

Surgical intervention is required for a displaced fracture of the dorsum of the base of the middle phalanx with articular surface involvement, as this type of fracture requires operative fixation to restore joint congruity and prevent long-term complications such as post-traumatic arthritis. 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 fractures with displacement >3mm or articular step-off require surgical intervention 1
• Fractures involving more than one-third of the articular surface require surgical fixation 1
• Interfragmentary gap >3mm is an indication for surgical intervention 1
• Joint instability or incongruity requires surgical fixation 1

Surgical Options

1. Open Reduction and Internal Fixation (ORIF):

   • Preferred for displaced intra-articular fractures of the middle phalanx 1, 3
   • Allows direct visualization and anatomic reduction of the articular surface 3

2. Dynamic External Fixation:

   • Useful for unstable intra-articular fractures of the middle phalanx 1
   • Provides stability while allowing early motion 1

3. Closed Reduction and Kirschner Wire Fixation:

   • An option for dorsal fracture-dislocations of the proximal interphalangeal joint 4
   • Long-term follow-up (16 years) shows satisfactory results with this technique 4

4. Arthroscopic-Assisted Reduction:

   • Useful for improved diagnostic accuracy and treatment of intra-articular fractures 1
   • Allows visualization of the articular surface during reduction 2

Post-Operative Management

• Early active motion exercises should be initiated as soon as stability allows to prevent stiffness 1
• Radiographic follow-up at approximately 3 weeks and at the time of hardware removal to confirm adequate healing 1
• For Kirschner wire fixation, wires are typically removed after 3-4 weeks when radiographic healing is evident 4

Expected Outcomes and Complications

• 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
• Long-term outcomes after proper surgical treatment show good stability and congruity with satisfactory functional results 3

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
• Failure to achieve anatomic reduction of the articular surface can lead to degenerative changes and functional limitations 3
• Operative fixation resulting in >2 mm of residual articular surface step-off should be avoided as it can lead to long-term complications such as osteoarthritis 2