Management of Fifth Finger Middle Phalanx Fractures
For most middle phalanx fractures of the pinky finger, a basic finger splint is sufficient if the fracture is non-displaced or minimally angulated (<10 degrees), but you must first obtain three-view radiographs to rule out displacement, significant angulation, or articular involvement that would require surgical referral. 1, 2
Initial Imaging Requirements
Before splinting, you must obtain proper radiographic evaluation:
- Three-view radiographs (PA, lateral, and oblique) are mandatory to detect displacement, angulation, and articular involvement 1
- An internally rotated oblique projection in addition to standard views increases diagnostic yield for phalangeal fractures 3, 1
- Two views alone are inadequate and represent a common pitfall that can miss significant fracture patterns 1
Decision Algorithm for Splinting vs. Referral
Splint with Basic Finger Splint (Non-operative):
- Non-displaced fractures 4, 2
- Minimal angulation (<10 degrees) 2
- No articular surface involvement 5
- Stable fracture patterns 6
Requires Surgical Referral:
- Angulation ≥10 degrees 2
- Displacement >3mm 7
- Intra-articular involvement with articular incongruity 4, 8
- Unstable fracture patterns 8, 6
- Malrotation of any degree 2
Proper Splinting Technique
If the fracture meets criteria for non-operative management:
- Use a rigid finger splint that immobilizes the PIP joint while allowing MCP joint motion 1
- The splint should be padded and comfortably tight but not constrictive (you should be able to slip a finger under it) 1, 7
- Position the finger in the position found without attempting to straighten it 7
- Duration: Continue rigid splinting for 3-4 weeks 1
Critical Early Motion Protocol
Begin active finger motion exercises immediately for all unaffected joints to prevent the most functionally disabling complication—hand stiffness 1, 7:
- Active motion does not adversely affect adequately stabilized fractures 1, 7
- Delayed motion significantly increases risk of hand stiffness, which can be extremely difficult to treat and may require surgical intervention 1
- Move unaffected fingers through complete range of motion regularly 7
Follow-up Requirements
- Obtain radiographic follow-up at approximately 3 weeks to assess healing and maintenance of alignment 1, 7
- Transition to aggressive finger and hand motion exercises when immobilization is discontinued 1
Common Pitfalls to Avoid
- Over-immobilization: Using rigid splinting when buddy taping would suffice leads to unnecessary stiffness 1
- Inadequate initial radiographs: Obtaining only two views is insufficient and misses fracture patterns 1
- Missing rotational deformity: Always assess the digital cascade clinically for rotational malalignment, as this requires surgical correction 2, 6
- Delayed recognition of instability: Close monitoring is essential as some fractures that appear stable initially may displace 6