Treatment for Distal Phalanx Dorsal Avulsion Fracture
For a distal phalanx dorsal avulsion fracture, strict splint immobilization for 8 weeks is the recommended treatment approach. 1
Initial Assessment
- Standard 3-view radiographic examination (PA, lateral, and oblique views) is essential for proper evaluation of 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 fracture characteristics 2
Treatment Algorithm
Conservative Management (Non-displaced fractures)
- For non-displaced dorsal avulsion fractures (mallet finger), strict splint immobilization of the distal interphalangeal (DIP) joint in extension for 8 weeks is required 1
- A removable splint that immobilizes only the DIP joint while allowing proximal interphalangeal (PIP) joint motion should be applied 3
- Active finger motion exercises for non-immobilized joints should be performed to prevent stiffness 3
Surgical Indications (When referral is needed)
- Displacement >3mm or articular step-off requires surgical intervention 4
- Fractures involving more than one-third of the articular surface require surgical fixation 2
- Interfragmentary gap >3mm is an indication for surgery 4
- Joint instability or incongruity requires surgical fixation 4
Follow-up Protocol
- Radiographic follow-up should be performed at approximately 3 weeks post-immobilization to assess healing 3
- Additional radiographic evaluation should be done at the time of immobilization removal to confirm adequate healing 3
Potential Complications
- Joint stiffness is one of the most functionally disabling complications and can be minimized with appropriate treatment and early motion of non-immobilized joints 4, 3
- Immobilization-related adverse events occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 4
- Without proper treatment, intra-articular fractures can lead to joint incongruity and subsequent post-traumatic arthritis 4, 3
Pitfalls to Avoid
- Avoid inadequate immobilization duration, as this can lead to non-union or malunion 1
- Avoid conservative management with simple splinting for displaced intra-articular fractures, as this leads to poor outcomes 4
- Avoid immobilizing joints unnecessarily, as this increases the risk of stiffness 3
Special Considerations
- Dorsal avulsion fractures differ from volar avulsion fractures (flexor digitorum profundus avulsions), which typically require surgical intervention 1, 5
- While some authorities disagree, non-operative treatment is generally preferred for dorsal articular fractures (mallet fractures) 6
- Patient compliance with splinting is crucial for successful outcomes, as improper splinting can lead to treatment failure 1