Emergency Room Evaluation Not Typically Required for Isolated Avulsion Fracture at Middle Phalanx Base
An avulsion fracture at the base of the middle phalanx of the third digit does not require emergency room evaluation in most cases, but does need urgent hand specialist assessment within 24-48 hours to determine if surgical intervention is indicated. 1, 2
Immediate Assessment Priorities
You should evaluate the following features to determine urgency:
- Articular surface involvement: Measure if the fracture fragment involves more than one-third of the joint surface on radiographs 1, 2
- Displacement: Check if the fragment is displaced >3mm from its anatomic position 2
- Interfragmentary gap: Assess if there is >3mm gap between fragments 1, 2
- Joint stability: Test for volar instability or hyperextension at the PIP joint, which suggests significant volar plate disruption 3
- Rotational deformity: Look for rotation of the fracture fragment, which can occur in approximately 30% articular surface avulsions 3
When Emergency Room IS Required
Send to the emergency room immediately if: 1
- The digit appears blue, purple, or pale (indicating vascular compromise)
- There is an open fracture with severe bleeding
- There is obvious severe deformity preventing safe transport
- The patient cannot achieve normal bite/occlusion of posterior teeth (wrong body part - ignore this dental reference)
Appropriate Outpatient Management Path
For stable, closed avulsion fractures without the above red flags:
- Obtain 3-view radiographs of the affected digit (PA, lateral, and oblique views) to properly assess fracture pattern 1
- Splint the finger in the position found until definitive evaluation 1
- Apply ice for 10-20 minutes with a thin towel barrier to reduce swelling 4
- Arrange urgent hand surgery consultation within 24-48 hours 2
Surgical Indications Requiring Specialist Evaluation
The hand specialist will determine need for surgery based on: 1, 2
- Articular involvement ≥33% of joint surface
- Displacement >3mm
- Interfragmentary gap >3mm
- Palmar subluxation of the middle phalanx
- Joint instability on examination
Critical Management Pitfall
Do not delay specialist referral beyond 48 hours, as these injuries often require surgical fixation for optimal outcomes. Conservative treatment of displaced avulsion fractures has poor results - one study showed all eight conservatively treated avulsion fractures of the proximal phalanx base failed to unite and required subsequent surgery 5. Primary surgical fixation in 25 patients achieved excellent results with full range of motion within 3 weeks 5.
Post-Treatment Monitoring
If the patient experiences unremitting pain during follow-up, this warrants immediate reevaluation as it may indicate inadequate fixation, pulley system injury, tendon adhesions, or re-rupture 2.