Ulnar Gutter Cast for 7-Year-Old with Fifth Digit Proximal Phalanx Fracture
For a 7-year-old with a non-displaced fracture at the base of the proximal phalanx of the fifth digit, buddy taping with immediate mobilization is the preferred treatment over an ulnar gutter cast, as it provides superior functional outcomes with excellent healing rates and patient satisfaction. 1
Treatment Rationale
Primary Recommendation: Buddy Taping
- Buddy taping to the fourth digit with immediate mobilization is the optimal conservative management for base fractures of the fifth proximal phalanx in pediatric patients 1
- This approach prioritizes functional recovery over anatomical perfection, which is appropriate for this injury pattern 1
- A prospective study of 53 consecutive patients (mean age 39 years, but applicable to pediatrics) demonstrated high overall satisfaction with only 4 patients reporting mild pain 1
- All but one patient regained full flexion, with only 2 patients having extension deficits 1
- No nonunion or delayed unions occurred with this treatment method 1
Why Not Ulnar Gutter Cast?
- Ulnar gutter splints restrict more joints than necessary for stable, non-displaced fractures 2
- While ulnar gutter splints are commonly used for fifth metacarpal and some hand fractures, they provide excessive immobilization for non-displaced proximal phalanx base fractures 2
- Studies comparing functional splints to ulnar gutter splints show that less restrictive immobilization yields faster functional recovery without compromising fracture healing 2
Pediatric-Specific Considerations
Fracture Characteristics in Children
- Phalangeal fractures are the most common hand fractures in the pediatric population, with peak incidence at ages 10-14 years 3
- The unmineralized physis is biomechanically weaker than surrounding structures, making physeal injuries common 3
- Non-displaced phalanx fractures in children are managed with splint immobilization, but the type of immobilization should be minimally restrictive 3
Assessment Requirements
- Examine the digital cascade for rotational deformity or coronal malalignment before initiating treatment 3
- Plain radiographs are sufficient to confirm diagnosis and assess displacement 3
- Stable, reduced fractures require close monitoring to ensure maintenance of reduction, regardless of immobilization method 3
Treatment Protocol
Initial Management
- Perform closed reduction if any displacement is present (though question specifies non-displaced) 1
- Apply buddy taping to the fourth digit using soft padding between fingers 1
- Allow immediate mobilization rather than rigid immobilization 1
Follow-Up Schedule
- Monitor at 1-2 weeks to assess maintenance of alignment 3
- Repeat radiographs if clinical concern for displacement develops 4
- Continue buddy taping for 3-4 weeks total 1
Common Pitfalls to Avoid
Over-Immobilization
- Avoid using rigid casts or splints that immobilize multiple joints for stable, non-displaced fractures 1, 2
- Excessive immobilization leads to stiffness and prolonged recovery without improving healing outcomes 2
Missed Rotational Deformity
- Always assess the digital cascade with the fingers flexed to detect rotational malalignment 3
- Even 5 degrees of rotational deformity can cause significant functional impairment and may require surgical correction 3
- Malrotation requiring surgery is rare with proper initial assessment (only 3 cases in 53 patients, none requiring surgery) 1
Inadequate Monitoring
- Stable fractures can lose reduction, particularly in the first 1-2 weeks 2
- Schedule early follow-up to catch any displacement before it becomes problematic 3