What is the initial treatment for a first distal phalangeal fracture?

Initial Treatment for Distal Phalangeal Fracture

Uncomplicated distal phalangeal fractures should be treated with splinting of the distal interphalangeal (DIP) joint for 4-6 weeks, combined with immediate active motion exercises of all unaffected finger joints. 1

Initial Imaging Requirements

• Obtain three-view radiographs (posteroanterior, lateral, and oblique) to adequately detect fractures and assess for displacement, angulation, or articular involvement 2
• An internally rotated oblique projection in addition to standard views increases diagnostic yield for phalangeal fractures 2
• Two-view examinations alone are insufficient for detecting phalangeal fractures 2

Treatment Algorithm Based on Fracture Pattern

Non-Displaced or Minimally Displaced Shaft/Tuft Fractures

• Splint the DIP joint in extension or slight flexion for 4-6 weeks 1
• These fractures typically result from crush injuries to the fingertip 1
• Begin immediate active motion exercises for all unaffected joints (proximal interphalangeal and metacarpophalangeal joints) 2, 3

Displaced or Comminuted Shaft/Neck Fractures

• These fractures are prone to symptomatic nonunion and may require early surgical fixation with interfragmentary screw fixation 4
• Oblique fractures are particularly prone to displacement and warrant close monitoring 4
• If initially treated nonoperatively, obtain weekly radiographs for the first 3 weeks to detect displacement 5

Mallet Finger (Dorsal Avulsion Fractures)

• Require strict continuous splint immobilization of the DIP joint in extension for 8 weeks 1
• These result from forced flexion against resistance 1
• Involvement of >1/3 of the articular surface, palmar displacement of the distal phalanx, or interfragmentary gap >3mm requires operative fixation 2

Flexor Digitorum Profundus Avulsion Fractures

• These volar base avulsion fractures usually require surgical intervention 1
• Result from forceful extension of the DIP joint when flexed 1

Critical Early Motion Protocol

Active finger motion exercises must begin immediately for all unaffected joints to prevent finger stiffness, which is one of the most functionally disabling complications. 2, 3

• Finger motion does not adversely affect adequately stabilized distal phalangeal fractures regarding reduction or healing 2, 6
• Hand stiffness can be extremely difficult to treat after fracture healing, potentially requiring multiple therapy visits or additional surgery 2
• This intervention is cost-effective and provides significant impact on patient outcome 2

Follow-Up Protocol

• Obtain radiographic follow-up at approximately 3 weeks to assess healing 6, 7
• Repeat radiographs at the time of immobilization removal to confirm adequate healing 6, 7
• If nonoperative treatment is chosen for displaced fractures, weekly radiographs for 3 weeks are essential as these fractures frequently displace 5

Common Pitfalls to Avoid

• Over-immobilization: Do not immobilize unaffected joints, as this leads to unnecessary stiffness 3
• Inadequate initial radiographs: Two views are insufficient; always obtain three views including oblique projections 2
• Delayed recognition of displacement: Fractures initially appearing stable can displace, requiring close radiographic monitoring in the first 3 weeks 5
• Failure to initiate early motion: Delaying active motion exercises of unaffected joints significantly increases the risk of hand stiffness 2, 3

Special Considerations

• Symptomatic nonunion can develop in displaced or comminuted fractures, manifesting as pain or instability 4
• Open reduction and interfragmentary screw fixation is effective for symptomatic nonunion, with all fractures uniting at a mean of 4.2 months 4
• Fractures can be surgically fixed even 8 weeks after injury if nonoperative treatment fails 5