Treatment of Chronic Intraarticular Fracture of the Fifth Middle Phalanx
For this 48-year-old male with a 3-month-old intraarticular fracture of the proximal head of the fifth middle phalanx, surgical intervention with osteotomy, open reduction, internal fixation, and bone grafting is the recommended treatment to restore joint anatomy and function. 1
Rationale for Surgical Management
At 3 months post-injury, this fracture is now a malunited intraarticular fracture requiring corrective osteotomy rather than acute fracture management. 1 The presence of articular surface impaction on X-ray indicates significant joint surface disruption that will not resolve with conservative measures at this late stage. 1
Surgical Technique
The "shotgun approach" should be used, which involves:
- Full exposure of the articular surface by dislocating the joint through hyperextension to visualize the malunited joint surface 1
- Osteotomy and mobilization of small osteochondral fragments to restore the cup-shaped contour of the middle phalangeal base 1
- Rigid internal fixation using cerclage wire, mini-screws (1.5-mm interfragmentary screws oriented dorsal to volar), or a combination 2, 1
- Bone grafting from the distal radius or ipsilateral radial styloid placed beneath disimpacted fragments to support the articular surface 2, 1
Expected Outcomes
Published results for this specific surgical approach show:
- Functional range of motion achieved in 9 of 10 patients 1
- Pain reduction from average preoperative score of 9.1/10 to 0.8/10 postoperatively 1
- Return to work at average of 13 weeks post-surgery 1
- Grip and pinch strength recovery to 95% and 90% of the unaffected side, respectively 1
Postoperative Rehabilitation
Early range-of-motion exercises should begin within the first postoperative days to prevent stiffness while maintaining stable fixation. 3, 4
- Finger motion exercises should be initiated immediately after stable fixation is achieved 3
- Avoid prolonged immobilization, which leads to stiffness and poorer functional outcomes 4, 5
- Moderate limitations of distal interphalangeal joint motion are common and should be anticipated 1
Critical Pitfalls to Avoid
- Delaying surgical intervention further - outcomes are negatively affected by prolonged delay and progressive cartilage wear of the proximal phalanx head 1
- Attempting conservative management at this late stage (3 months) - the fracture is already malunited and requires corrective osteotomy 1
- Inadequate visualization of the articular surface - full joint dislocation is necessary to properly restore anatomy 1
- Insufficient bone grafting - support beneath disimpacted fragments is critical for maintaining reduction 2, 1
- Overly aggressive early therapy - while early motion is important, excessive force may compromise fixation 3
Additional Considerations
Since this patient is 48 years old with a recent fracture, evaluation for underlying bone health and fracture risk should be performed, including assessment for secondary osteoporosis risk factors. 3 However, this is a traumatic injury pattern rather than a fragility fracture, so osteoporosis workup is lower priority unless other risk factors are present.