What is the treatment guideline for fractures of the 2nd and 3rd proximal phalanges in an 82-year-old female?

Treatment of Proximal Phalanx Fractures (2nd and 3rd Digits) in an 82-Year-Old Female

For an 82-year-old female with proximal phalanx fractures of the 2nd and 3rd digits, initial management should prioritize closed reduction with buddy taping or splinting in the intrinsic-plus position for stable fractures, while unstable fractures require surgical fixation—but the overarching priority must be comprehensive fragility fracture evaluation and osteoporosis treatment, as hand fractures in this age group represent sentinel events for underlying bone disease and future hip fractures.

Initial Assessment and Fracture Characterization

• Obtain standard three-view radiographs (posteroanterior, lateral, and oblique) to characterize fracture pattern, displacement, and angulation 1
• Assess fracture stability based on: displacement >2mm, rotational deformity, comminution, and ability to maintain reduction 2, 3
• Provide immediate multimodal analgesia including acetaminophen and consider nerve blocks while avoiding NSAIDs in elderly patients 4
• Evaluate for rotational malalignment by examining fingertip convergence with flexion—all fingers should point toward the scaphoid tubercle 3

Treatment Algorithm Based on Fracture Stability

For Stable, Non-Displaced Fractures:

• Apply buddy taping to adjacent finger with intrinsic-plus splinting: wrist extended 30°, metacarpophalangeal joints flexed 70-90°, interphalangeal joints free 5
• This position tightens the extensor aponeurosis to provide natural splinting while allowing immediate active range of motion in the interphalangeal joints 5
• Begin active finger exercises immediately within the first postoperative days to prevent stiffness 6, 5
• Immobilize for 3-4 weeks with weekly radiographic monitoring 3

For Unstable or Displaced Fractures:

• Surgical fixation is indicated for: angulation >10°, displacement >2mm, rotational deformity, or inability to maintain closed reduction 2, 3
• Surgical options in order of preference for this elderly patient:
  • Closed reduction with percutaneous Kirschner wire fixation for transverse and short oblique fractures—minimizes soft tissue dissection and scarring 2, 7
  • Closed reduction with intramedullary screw fixation (CRIMEF) shows superior return to function and total active motion, though technically demanding 7
  • Open reduction with plate fixation reserved for comminuted fractures or bicondylar patterns 2

Critical Geriatric-Specific Considerations

This fracture represents a fragility fracture requiring systematic evaluation and treatment to prevent future hip fractures, which carry 30% one-year mortality in this age group 4:

• Implement immediate orthogeriatric co-management to reduce mortality and improve functional outcomes 4
• Order vitamin D, calcium, and parathyroid hormone levels during initial visit 4
• Schedule outpatient DEXA scan and refer to bone health clinic 4, 8
• Consider initiating anti-osteoporotic therapy (alendronate, risedronate, or zoledronic acid) even before DEXA results in patients with typical fragility fracture patterns 8
• Evaluate fall risk factors including: home safety hazards, vision impairment, medication side effects, and balance deficits 4

Rehabilitation Protocol

• Begin active range-of-motion exercises in the proximal and distal interphalangeal joints immediately after stable fixation or splinting 6, 5
• Avoid prolonged immobilization beyond 4 weeks, which leads to permanent stiffness and poor functional outcomes 6, 5
• The goal is achieving bony healing and free mobility simultaneously, not sequentially 5
• Implement balance training and multidimensional fall prevention programs for long-term secondary fracture prevention 4

Common Pitfalls to Avoid

• Do not treat this as an isolated hand injury—failure to address underlying osteoporosis leaves the patient at 86% increased risk of subsequent hip fracture within 2 years 4
• Avoid overly aggressive early therapy that may compromise fixation stability 6
• Do not use static plaster casting for extended periods, which causes interphalangeal joint contractures 5
• Avoid NSAIDs for pain control in elderly patients due to renal and gastrointestinal risks 4

Expected Outcomes

• With appropriate functional treatment, 86% of patients achieve full range of motion 5
• When extension limitation occurs, it typically does not exceed 20° at the proximal interphalangeal joint 5
• All fractures should achieve union without delayed healing or pseudarthrosis with proper management 5

Follow-Up Requirements

• Weekly radiographs for first 3 weeks to monitor fracture alignment 3
• Assess for pressure sores, nutritional status, and cognitive function at each visit given age and frailty 4
• Ensure systematic follow-up for osteoporosis treatment adherence 8
• Monitor for complications including malunion, rotational deformity, and tendon adhesions 3