What is the treatment for a proximal phalanx fracture?

Treatment for Proximal Phalanx Fractures

The treatment of proximal phalanx fractures should focus on dynamic treatment with a custom-molded splint that immobilizes the wrist and metacarpophalangeal joints while allowing motion of the interphalangeal joints to achieve bone healing and recovery of motion simultaneously. 1

Initial Assessment and Management

• Pain management is essential and should include appropriate analgesia such as paracetamol, while avoiding NSAIDs in patients with renal dysfunction 2
• Radiographic evaluation should include anteroposterior, lateral, and oblique views to assess fracture pattern, displacement, and angulation 3
• Fractures should be classified based on:
  • Location (proximal, middle, or distal third of the phalanx)
  • Pattern (transverse, oblique, spiral, comminuted)
  • Displacement and angulation
  • Presence of intra-articular extension 4

Treatment Options Based on Fracture Characteristics

Non-Displaced or Minimally Displaced Fractures

• Dynamic treatment with a dorsopalmar plaster splint and finger splint that:
  • Immobilizes the wrist in 30 degrees of dorsiflexion
  • Positions the metacarpophalangeal joints in 70-90 degrees of flexion (intrinsic plus position)
  • Allows active motion of the interphalangeal joints 1
• This position creates tension in the extensor aponeurosis, which covers two-thirds of the proximal phalanx and provides firm splinting of the fracture 1
• Buddy splinting can be used for fractures with minimal angulation (less than 10 degrees) 3

Displaced Fractures

• Closed reduction followed by dynamic splinting for fractures that can be adequately reduced 5
• Surgical intervention is indicated for:
  • Fractures with angulation greater than 10 degrees
  • Rotational deformity
  • Significant displacement
  • Unstable fracture patterns
  • Intra-articular fractures 4, 3

Surgical Options

• Kirschner wire fixation is preferred for transverse and short oblique proximal phalanx fractures 4
• Lag screws are recommended for spiral long oblique phalanx shaft fractures 4
• Plate fixation is indicated for comminuted proximal phalanx fractures 4

Rehabilitation Protocol

• Duration of splinting is typically 5-6 weeks (average 36 days), considering the usual progression of fracture healing in closed phalangeal fractures 5
• Early active exercises of the interphalangeal joints should be encouraged while the fracture is protected by the splint to prevent stiffness 1
• After splint removal, aggressive motion exercises are necessary to achieve optimal outcomes 6
• Avoid overly aggressive physical therapy as it may increase the risk of fixation failure 6

Potential Complications and Monitoring

• Regular radiographic assessment should be performed to ensure proper bone healing 2
• Monitor for common complications:
  • Joint stiffness, particularly extension limitation of the proximal interphalangeal joint (most common) 1
  • Malrotation or angular deformity
  • Delayed union or nonunion (rare with appropriate treatment) 1

Special Considerations

• Compression-type fractures may not be suitable for static traction splints due to the risk of tenodesis effect causing severe active flexion deficit 5
• Patient education about the injury, potential complications, and expected outcomes is essential 6
• The goal of treatment should be to achieve both bony healing and free mobility simultaneously, not sequentially 1, 7

Treatment Algorithm

1. Assess fracture stability and displacement on radiographs
2. For stable, non-displaced fractures: Dynamic splinting
3. For displaced but reducible fractures: Closed reduction followed by dynamic splinting
4. For unstable, irreducible, or intra-articular fractures: Surgical fixation
5. Begin early protected motion of interphalangeal joints regardless of treatment method
6. Continue treatment for 5-6 weeks with regular radiographic monitoring
7. Initiate aggressive motion exercises after splint removal 1, 7, 4, 3