Splint for Nondisplaced Avulsion Fracture of the First Distal Phalanx
For a nondisplaced avulsion fracture of the first distal phalanx, a removable splint that immobilizes only the distal interphalangeal (DIP) joint while allowing proximal interphalangeal (PIP) joint motion is recommended. 1
Assessment and Diagnosis
- Standard 3-view radiographic examination (PA, lateral, and oblique views) is essential for proper evaluation of phalangeal fractures 1
- An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 1
- CT without IV contrast may be necessary when radiographs are equivocal to better evaluate fracture characteristics 1
Treatment Approach
- For nondisplaced avulsion fractures of the distal phalanx, conservative management with splinting is appropriate 1, 2
- The splint should specifically immobilize only the DIP joint while allowing PIP joint motion to prevent unnecessary stiffness 1
- Duration of splinting for uncomplicated distal phalanx fractures is typically 4-6 weeks 2
- Active finger motion exercises for non-immobilized joints should be performed to prevent stiffness 1
Splint Selection Considerations
- For dorsal avulsion fractures (mallet finger) specifically, a modified dorsal finger splint may be used to prevent mallet finger deformity 3
- Removable splints offer advantages of increased comfort and hygiene compared to casting, with no significant difference in clinical and radiologic outcomes 4
Follow-up Protocol
- Radiographic follow-up should be performed at approximately 3 weeks post-immobilization to assess healing 1
- Additional radiographic evaluation should be done at the time of immobilization removal to confirm adequate healing 1
When to Consider Referral for Surgical Management
- Fractures involving more than one-third of the articular surface require surgical fixation 1
- Displacement >3mm or articular step-off requires surgical intervention 1
- Interfragmentary gap >3mm is an indication for surgery 1
- Joint instability or incongruity requires surgical fixation 1
Potential Complications and Pitfalls
- Joint stiffness is one of the most functionally disabling complications and can be minimized with appropriate treatment and early motion of non-immobilized joints 1
- Immobilization-related adverse events occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 1
- Avoid immobilizing joints unnecessarily, as this increases the risk of stiffness 1
- Without proper treatment, intra-articular fractures can lead to joint incongruity and subsequent post-traumatic arthritis 1
- Early diagnosis is critical - missed injuries can lead to poor outcomes, as seen in cases where tendon injuries are overlooked due to focus on the fracture 5