Management of Comminuted Distal Phalanx Fracture of the Fourth Finger
Most comminuted distal phalanx fractures of the fourth finger will heal correctly without surgical intervention, provided they are minimally displaced and do not involve significant articular surface disruption or tendon avulsion.
Initial Assessment and Imaging
- Radiography is essential as the initial imaging for suspected finger fractures, with at least 3 views recommended (posteroanterior, lateral, and oblique) to properly evaluate the fracture pattern 1
- For distal phalanx fractures, radiographs should assess:
- Degree of displacement
- Articular involvement
- Comminution pattern
- Associated soft tissue injuries 2
Treatment Algorithm for Distal Phalanx Fractures
Conservative Management (Indicated for Most Cases)
- Rigid immobilization with a splint for 3-6 weeks is indicated for minimally displaced comminuted fractures 2
- Conservative treatment is appropriate for most distal phalanx fractures as they typically heal well without specific intervention for the fracture itself 3
- Active finger motion exercises should be performed following diagnosis to prevent stiffness, which is one of the most functionally disabling adverse effects 1
Surgical Intervention (Reserved for Specific Scenarios)
- Surgery should be considered when:
- Fracture fragment displacement is greater than 3mm 1
- Involvement of more than one-third of the articular surface 1
- Palmar displacement of the distal phalanx 1
- Interfragmentary gap of >3mm 1
- Symptomatic non-union develops (manifesting as pain and/or instability) 4
- Displaced articular fractures on the palmar side associated with flexor digitorum profundus tendon avulsion 3
Post-Treatment Management
- Hand stiffness is one of the most functionally disabling adverse effects following fracture treatment 1
- A home exercise program is an effective option for patients after fracture immobilization 1
- Instructing the patient to move the fingers regularly through a complete range of motion helps minimize the risk of stiffness complications 1
- Finger motion does not have adverse effects on an adequately stabilized fracture in regard to reduction or healing 1
Monitoring and Complications
- Unremitting pain during follow-up warrants reevaluation, as this may indicate complications 1, 5
- If non-union develops and becomes symptomatic, open reduction and interfragmentary screw fixation has shown excellent results with minimal morbidity 4
- Patients should be monitored for:
Common Pitfalls and Caveats
- Failure to encourage early finger motion can lead to significant stiffness that is difficult to treat after fracture healing 1
- Overlooking displacement or articular involvement can lead to poor functional outcomes 2
- Children with distal phalanx epiphyseal fractures may have unsatisfactory results and should be monitored closely 6
- Comminuted fractures in children often take the form of longitudinal splitting and generally have good outcomes with conservative management 6