What is the initial management for an acute ununited fracture of the first distal phalanx?

Initial Management of Acute Ununited Fracture of the First Distal Phalanx

For acute ununited fractures of the first distal phalanx, initial management should include a standard 3-view radiographic examination followed by immobilization with a removable splint that immobilizes only the distal interphalangeal (DIP) joint while allowing proximal interphalangeal (PIP) joint motion. 1, 2

Diagnostic Evaluation

• Standard 3-view radiographic examination (PA, lateral, and oblique views) is essential for proper evaluation of phalangeal fractures 3, 2
• An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 3, 2
• CT without IV contrast may be necessary when radiographs are equivocal to better evaluate fracture characteristics 3, 2

Treatment Algorithm

Non-displaced Fractures (Conservative Management)

• Apply a removable splint that immobilizes only the DIP joint while allowing PIP joint motion 1, 2
• Duration of immobilization should typically last 3-4 weeks 1
• Active finger motion exercises for non-immobilized joints should be performed to prevent stiffness 1, 2
• Rigid immobilization is preferred over removable splints for displaced fractures that have been reduced 3

Surgical Indications

• Fractures with displacement >3mm or articular step-off require surgical intervention 3, 2
• Fractures involving more than one-third of the articular surface require surgical fixation 3, 2
• Interfragmentary gap >3mm is an indication for surgery 3, 2
• Joint instability or incongruity requires surgical fixation 2

Special Considerations

• Displaced articular fractures on the palmar side are associated with avulsion of the flexor digitorum profundus tendon and require surgical intervention 4
• Dorsal articular fractures (mallet fractures) can typically be treated non-operatively 4
• For unstable fractures requiring surgical fixation, multiple Kirschner wire fixation is recommended as the most predictable method of treatment 5
• Olecranon bone grafting combined with Kirschner wire fixation has been shown effective for established nonunions of the distal phalanx 6

Follow-up Protocol

• Radiographic follow-up should be performed at approximately 3 weeks post-immobilization to assess healing 1, 2
• Additional radiographic evaluation should be done at the time of immobilization removal to confirm adequate healing 1, 2

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 2, 7
• Immobilization-related adverse events occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 1, 2
• Without proper treatment, intra-articular fractures can lead to joint incongruity and subsequent post-traumatic arthritis 1, 2

Pitfalls to Avoid

• Avoid conservative management with simple splinting for displaced intra-articular fractures, as this leads to poor outcomes 2
• Avoid immobilizing joints unnecessarily, as this increases the risk of stiffness 2
• Avoid prolonged immobilization of the PIP joint, as this can lead to permanent stiffness 2, 8