What are the treatment guidelines for a suspected acute nondisplaced fracture involving the proximal to mid shaft of the proximal phalanx of the fifth digit in a pediatric patient?

Treatment of Suspected Acute Nondisplaced Proximal Phalanx Fracture (Fifth Digit) in a 10-Year-Old

Immobilize the fracture with a rigid splint (buddy taping to the ring finger or an ulnar gutter splint) for 3 weeks if clinically healed at that point, rather than the traditional 5 weeks, as this provides equivalent outcomes with faster return to function in pediatric proximal phalanx fractures. 1

Initial Imaging

• Obtain radiographs with at least 2 views (PA and lateral) as the initial imaging modality of choice 2
• Radiographs are rapidly obtained, well tolerated, and sufficient for diagnosis and treatment planning when a nondisplaced fracture is demonstrated 3
• Assess for displacement (>2-3mm requires consideration of surgical intervention), articular involvement, and rotational alignment 2, 4

Conservative Management Protocol

Immobilization Strategy

• Use rigid immobilization with either buddy taping to the adjacent ring finger or an ulnar gutter splint 1, 4
• An intrinsic-plus splint position (MCP joint flexed, IP joints extended) is preferred for stable fractures to prevent stiffness while maintaining reduction 4
• Reassess at 3 weeks post-injury for clinical healing rather than automatically continuing immobilization to 5 weeks 1

Evidence-Based Duration

Recent high-quality pediatric evidence demonstrates that children with conservatively managed proximal phalanx fractures who are clinically healed at 3 weeks can safely discontinue immobilization at that point, with equivalent total active motion, grip strength, and functional outcomes compared to traditional 5-week protocols 1. This represents a significant practice change supported by Level 1 evidence in the pediatric population 1.

Follow-Up Protocol

• Schedule follow-up at 10-14 days to obtain repeat radiographs and ensure fracture position is maintained 2, 5
• Perform clinical assessment at 3 weeks to determine if the fracture is healed (absence of tenderness, ability to bear stress without pain) 1
• If clinically healed at 3 weeks, discontinue immobilization and begin active range of motion exercises 1
• If not clinically healed at 3 weeks, continue immobilization and reassess weekly 1

Assessment for Malrotation

Rotational malalignment is the most critical complication to identify early, as it requires immediate intervention:

• Examine finger alignment during active flexion - all fingers should point toward the scaphoid tubercle without crossing over adjacent digits (scissoring) 5
• Have the patient make a gentle fist and observe whether the fingernails align in parallel planes 5
• Compare the cascade of fingers to the contralateral hand 5
• Any persistent or worsening pain during the first few weeks should prompt reevaluation for malrotation or loss of reduction 5

The overall rate of rotational malalignment requiring intervention is very low (0.93%) in properly managed pediatric proximal phalanx fractures 6.

Indications for Surgical Intervention

While the vast majority of nondisplaced proximal phalanx fractures in children are managed conservatively, consider surgical stabilization if:

• Fracture displacement exceeds 2-3mm despite closed reduction 2, 4, 6
• Rotational deformity (scissoring) is present and cannot be corrected with closed reduction 5, 6
• Loss of reduction occurs during the immobilization period 5, 6
• The fracture is inherently unstable (comminuted, oblique patterns with shortening) 4

Closed reduction with percutaneous K-wire fixation is the preferred surgical approach when intervention is needed, with axial pinning showing faster surgical duration and healing times compared to open reduction 7.

Critical Pitfalls to Avoid

• Do not automatically immobilize for 5 weeks - therapist assessment of clinical healing at 3 weeks is an appropriate indicator to discontinue immobilization in children 1
• Do not miss rotational malalignment - this must be assessed immediately and throughout treatment, as it becomes functionally disabling if not corrected early 5
• Do not delay active motion exercises for uninvolved joints - stiffness is the most functionally disabling complication and can be prevented with early mobilization of uninjured digits 5
• Be aware that flexor tendon entrapment, though rare, can occur with proximal phalanx base fractures and should be suspected if flexion limitation persists despite adequate immobilization 8

Expected Outcomes

With appropriate conservative management, pediatric patients typically regain full range of motion with no long-term functional deficits 1, 7, 6. Closed reduction maintains coronal angulation well (mean 5.8° at final follow-up) when post-reduction angulation is less than 10° 6.