Treatment of Comminuted and Mildly Displaced Small Finger Proximal Phalanx Fracture
For a comminuted and mildly displaced small finger proximal phalanx fracture, rigid immobilization in an intrinsic-plus position (wrist extended 30 degrees, metacarpophalangeal joint flexed 70-90 degrees) for 3-6 weeks combined with immediate active interphalangeal joint motion exercises is the recommended treatment approach. 1, 2
Initial Imaging Assessment
- Obtain at least 3-view radiographs (posteroanterior, lateral, and oblique) of the affected finger to properly evaluate the fracture pattern, degree of displacement, and articular involvement 3, 1
- Standard 2-view radiography is inadequate for detecting all fracture characteristics in finger injuries 3
Treatment Algorithm
Conservative Management (Preferred for Mildly Displaced Fractures)
Immobilization technique:
- Apply a dorsopalmar plaster splint with the wrist dorsiflexed 30 degrees and metacarpophalangeal joint flexed 70-90 degrees (intrinsic-plus position) 2
- This position creates tension in the extensor aponeurosis, which covers two-thirds of the proximal phalanx and provides firm fracture splinting 2
- Maintain rigid immobilization for 3-6 weeks 1, 4
Critical early mobilization:
- Begin active interphalangeal joint motion exercises immediately following diagnosis, even while the fracture is immobilized 1, 5
- Finger motion does not adversely affect adequately stabilized fractures regarding reduction or healing 1, 5
- Early active exercises prevent the most functionally disabling complication—finger stiffness 1, 5
Indications for Surgical Referral
Surgery should be considered when any of the following criteria are met:
- Fracture fragment displacement >3mm 1, 6
- Involvement of more than one-third of the articular surface 1, 6
- Interfragmentary gap >3mm 1
- Angulation >10 degrees 4
- Malrotation detected on clinical examination 5
Assessment for Malrotation
Examine finger alignment during active flexion:
- Have the patient actively flex all fingers together into a fist 5
- All fingers should point toward the scaphoid tubercle without crossing over adjacent digits 5
- Look for scissoring where the small finger crosses over or under the ring finger—this is the hallmark sign of rotational malalignment requiring immediate intervention 5
Post-Treatment Management
Follow-up radiographs:
- Obtain repeat radiographs at 10-14 days to ensure fracture position is maintained 5
- Continue radiographic monitoring for 3 weeks and at cessation of immobilization 3
Rehabilitation:
- A home exercise program is effective for patients after fracture immobilization 1
- Instruct the patient to move the fingers regularly through complete range of motion to minimize stiffness risk 1
- After splint removal (typically 3-6 weeks), nearly full range of motion should be regained within 3 weeks 2, 7
Common Pitfalls and Monitoring
Critical warning signs requiring reevaluation:
- Unremitting or worsening pain during the first few weeks may indicate complications such as malrotation or loss of reduction 1, 5
- Inability to achieve full active flexion without finger overlap suggests rotational malalignment requiring correction 5
Most important pitfall to avoid:
- Failure to encourage early interphalangeal joint motion leads to significant stiffness that is difficult to treat after fracture healing 1
- The combination of compression-type trauma with static immobilization can create a tenodesis effect with severe active flexion deficit 7
Expected Outcomes with Conservative Treatment
- Fracture consolidation occurs in essentially all cases with proper immobilization 2
- 86% of patients achieve full range of motion with functional treatment combining immobilization and early active motion 2
- When limitations occur, they typically involve extension deficit at the proximal interphalangeal joint up to 20 degrees in 14% of cases 2