What is the treatment for a comminuted and displaced small finger proximal phalanx fracture?

Treatment of Comminuted and Displaced Small Finger Proximal Phalanx Fracture

Comminuted and displaced proximal phalanx fractures of the small finger require surgical fixation with open reduction and internal fixation (ORIF), preferably using screw fixation via a midlateral approach when possible, or low-profile plate fixation when necessary, followed by immediate active range of motion exercises to prevent debilitating stiffness. 1, 2

Surgical Intervention is Indicated

• Displacement greater than 3mm or involvement of more than one-third of the articular surface mandates surgical treatment 3
• Comminuted proximal phalanx fractures generally require plate fixation to achieve adequate stability 1
• The combination of comminution and displacement in your patient makes conservative management inappropriate, as these fractures cannot maintain reduction with splinting alone 1

Optimal Surgical Technique

Fixation Method Selection

• Screw fixation should be prioritized whenever the fracture pattern allows, as plate fixation carries a 5.9-fold increased risk of postoperative finger stiffness compared to screw-only fixation 2
• When plate fixation is necessary for comminuted fractures, use low-profile titanium plates 2
• External fixation systems (such as the Ichi-Fixator) can be considered for severely comminuted intra-articular fractures at the base of the proximal phalanx, avoiding complications associated with plate prominence and extensor tendon interference 4

Surgical Approach

• Use a midlateral approach rather than dorsal approach whenever possible, as dorsal plate placement carries a 3.0-fold increased risk of postoperative stiffness 2
• Dorsal approaches risk interference with the central slip and lateral bands of the extensor mechanism, potentially causing extensor tendon rupture and plate prominence 4
• The midlateral approach provides adequate exposure while preserving the extensor apparatus 2

Critical Post-Operative Management

Immediate Mobilization Protocol

• Begin active finger motion exercises immediately following surgery—this is the single most important factor in preventing debilitating stiffness 5, 6, 3
• Finger motion does not adversely affect adequately stabilized fractures but significantly reduces the risk of stiffness, which is the most functionally disabling complication 5, 6
• Functional treatment achieves bony healing and free mobility simultaneously, not sequentially 7

Specific Exercise Regimen

• Institute active exercises in both the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints to prevent limitations of mobility and subsequent rotational/axial deformities 7
• A home exercise program is effective for patients after fracture stabilization 6, 3
• Instruct the patient to move the fingers regularly through complete range of motion 6

Monitoring for Complications

Assess for Malrotation

• Examine finger alignment during active flexion immediately post-operatively and at each follow-up, as rotational deformities become most apparent when fingers flex toward the scaphoid tubercle 5
• Look for scissoring during active flexion, where the small finger crosses over or under the ring finger—this is the hallmark sign of rotational malalignment 5
• Ask the patient to actively flex all fingers together into a fist and observe whether fingernails align in parallel planes 5
• Compare the cascade of fingers when making a gentle fist to the contralateral hand 5

Follow-Up Imaging

• Obtain repeat radiographs at 10-14 days to ensure fracture position is maintained 5
• Continue monitoring for proper fracture healing and restoration of finger function 6

Red Flags Requiring Intervention

• Any degree of persistent or worsening pain during follow-up warrants immediate reevaluation for malrotation or loss of reduction 5, 6
• Inability to achieve full active flexion without finger overlap suggests rotational malalignment requiring correction 5

Common Pitfalls to Avoid

• Failure to encourage early finger motion leads to significant stiffness that is difficult to treat after fracture healing—this is the most critical error in management 6
• Choosing dorsal plate placement when lateral or volar approaches are feasible triples the risk of stiffness 2
• Using plate fixation when screw fixation alone would suffice increases stiffness risk nearly six-fold 2
• Delaying mobilization beyond the immediate post-operative period significantly compromises functional outcomes 7