Is malrotation a concern in a patient with an oblique, non-displaced fracture of the proximal phalanx of the little finger, given the little finger's outward deviation and lack of overlap with other fingers, despite parallel nail beds when fingers are straight?

Assessment of Malrotation Concern in Proximal Phalanx Fracture

The slight outward deviation of the little finger you describe is likely NOT clinically significant malrotation and does not warrant immediate intervention, particularly given the parallel nail beds and absence of scissoring on cascade testing. 1

Clinical Assessment of Malrotation

The key clinical tests you've already performed are the most reliable indicators:

• Cascade sign: Your observation that fingers do not overlap or scissor when flexed is the critical finding—this indicates no functionally significant malrotation 1
• Nail bed alignment: Parallel nail beds when fingers are extended further confirms acceptable rotational alignment 1
• Slight outward deviation: Minor deviation away from the ring finger without overlap is common and typically represents soft tissue swelling, joint stiffness, or minor positioning rather than true bony malrotation 1, 2

Why This Is Likely Not Concerning

Clinically significant malrotation manifests as finger overlap (scissoring) during flexion, which you explicitly do not have. 1 The threshold for intervention in proximal phalanx fractures is malrotation that causes functional impairment through digit overlap, not minor positional variations. 2, 3

At 5 days post-injury with an oblique, non-displaced fracture, several factors explain the outward deviation:

• Soft tissue swelling: Edema commonly causes apparent positional changes that resolve as swelling subsides 1, 2
• Joint stiffness: Early immobilization stiffness can affect finger positioning without representing true malrotation 2
• Splint positioning: The intrinsic-plus position itself may create apparent deviation that differs from the final healed position 1
• Non-displaced fracture: Your fracture is specifically described as non-displaced, making significant rotational deformity unlikely 1

When Malrotation Requires Intervention

True malrotation requiring surgical correction presents with:

• Scissoring on cascade test: Fingers cross over adjacent digits during flexion 1, 2
• Non-parallel nail beds: Clear rotational malalignment visible when fingers extended 1
• Functional impairment: Inability to make a fist or grasp objects 3
• Rotational deformity >10-20 degrees: Measured clinically, not just visually apparent 2, 3

Recommended Approach

Continue your prescribed treatment (intrinsic-plus splinting for 3 weeks, then buddy taping) and reassess alignment after swelling resolves. 1 Specifically:

• Monitor through the splinting period: Most apparent deviations from swelling/stiffness resolve with healing 1, 2
• Repeat cascade testing at 2-3 weeks: When swelling has decreased, reassess for true scissoring 1
• Clinical follow-up with treating physician: Scheduled reassessment will identify any true malrotation requiring intervention 2
• Early mobilization with buddy taping: The planned transition to buddy loops at 3 weeks will reveal any functional rotational problems 1

Critical Pitfall to Avoid

Do not confuse early post-injury swelling and stiffness with true malrotation. 1, 2 Premature surgical intervention for apparent malrotation that would resolve with conservative treatment risks unnecessary complications including tendon adhesions, capsular contracture, and permanent stiffness. 2, 3 The definitive assessment occurs after swelling resolves and early mobilization begins, not at 5 days post-injury.

If scissoring develops or nail beds become clearly non-parallel as swelling resolves, then surgical correction would be indicated—but your current clinical findings do not suggest this will occur. 1, 2, 3