When are proximal phalanx fractures considered for surgical intervention?

Surgical Indications for Proximal Phalanx Fractures

Proximal phalanx fractures require surgical intervention when they are displaced, unstable, involve articular surfaces with significant displacement, or cannot maintain acceptable reduction with conservative management—specifically when angulation exceeds 10-15 degrees, there is rotational deformity, or more than one-third of the articular surface is involved.

Absolute Surgical Indications

Articular Fractures

• Bicondylar fractures of the proximal phalanx head typically require plate fixation due to inherent instability and need for anatomic reduction 1
• Unicondylar fractures with involvement of more than one-third of the articular surface require operative fixation to prevent long-term complications such as osteoarthritis 2
• Palmar displacement of fragments or interfragmentary gap >3 mm indicates need for surgery 2

Displaced Shaft Fractures

• Spiral long oblique shaft fractures are best managed with lag screw fixation to achieve stable compression 1
• Comminuted proximal phalanx fractures require plate fixation for adequate stability 1
• Transverse and short oblique fractures with unacceptable angulation (>10-15 degrees) or inability to maintain reduction need Kirschner wire fixation 1, 3

Rotational Deformities

• Any fracture with clinically evident malrotation requires surgical correction, as conservative management cannot adequately address this problem 1, 4

Relative Surgical Indications

Unstable Fracture Patterns

• Fractures that lose reduction after initial closed treatment should be considered for surgical stabilization 3
• Multiple fractures in the same hand may benefit from surgical fixation to facilitate early mobilization 4
• Fractures with significant soft tissue injury or open wounds typically require operative debridement and stabilization 4

Conservative Management Criteria

Conservative treatment with buddy taping and immediate mobilization is appropriate when:

• Fractures maintain acceptable reduction with <15 degrees of angulation and <1-2 mm of shortening 3
• No rotational deformity is present 5, 6
• Fractures are inherently stable (minimally displaced transverse or short oblique patterns) 1
• Base fractures of the fifth proximal phalanx, which can be successfully managed with buddy taping to the fourth digit 6

Conservative Treatment Protocol

• Dorsopalmar plaster splint with wrist dorsiflexed 30 degrees and metacarpophalangeal joints flexed 70-90 degrees (intrinsic plus position) for 3 weeks 5
• Immediate mobilization of interphalangeal joints to prevent stiffness 5
• This approach achieves 86% full range of motion at follow-up 5

Common Pitfalls to Avoid

• Accepting excessive angulation: More than 15 degrees of angulation leads to functional impairment and should prompt surgical intervention 3
• Missing rotational deformities: These are poorly tolerated and require operative correction even when other parameters seem acceptable 1, 6
• Delayed mobilization: Whether treated conservatively or surgically, early mobilization is critical to prevent joint stiffness 4, 5
• Inadequate fixation: Meticulous surgical technique with stable fixation is essential to allow early postoperative mobilization and prevent complications 4

Surgical Technique Selection

• Kirschner wires: Transverse and short oblique shaft fractures, metacarpal neck fractures 1
• Lag screws: Spiral long oblique shaft fractures requiring compression 1
• Plate fixation: Bicondylar head fractures, comminuted shaft fractures 1
• The goal is anatomic reduction with stable fixation allowing early mobilization 4