Treatment of Fifth Phalanx Fractures
Most fifth phalanx fractures can be successfully treated non-operatively with immobilization, while unstable fractures, articular incongruity, or open fractures require surgical intervention. 1
Initial Assessment
Evaluate for:
- Obvious deformity, swelling, or bruising 2
- Severe pain with movement or inability to move the digit 2
- Fracture stability, location (proximal, middle, or distal third), and pattern (transverse, oblique, comminuted) 1
- Articular involvement and soft tissue damage 1
- Rotational or angular deformity 3
Non-Operative Management (First-Line for Stable Fractures)
Rigid immobilization is preferred over removable splints for displaced fractures requiring non-surgical treatment. 2
Functional Dynamic Treatment Approach:
- Apply dorsopalmar plaster splint with finger splint 3
- Position wrist in 30° dorsiflexion and metacarpophalangeal joints in 70-90° flexion (intrinsic plus position) 3
- This position tautens the extensor aponeurosis, providing firm fracture splinting 3
- Initiate active exercises in interphalangeal joints early to prevent stiffness 3
- This approach achieves bony healing and mobility simultaneously, not sequentially 3
Expected Outcomes:
- 86% of patients achieve full range of motion with functional treatment 3
- All fractures consolidate without delayed union or pseudarthrosis 3
- When limitations occur, they are typically minor (extension lag <20° or fingertip-palm distance <1.5cm) 3
Surgical Indications
Surgery is indicated for:
- Open fractures (absolute indication) 2
- Unstable injuries despite closed reduction 1
- Articular incongruity or displacement 1, 4
- Concomitant soft tissue damage requiring repair 1
- Fractures where anatomy restoration is achievable only operatively 1
Specific Fracture Patterns Requiring Surgery:
- Unstable type-1 avulsion fractures of the base 4
- Type-2 avulsions at risk for boutonniere deformity 4
- Any fracture displacing articular cartilage surfaces 4
Surgical Options
- Percutaneous pinning with Kirschner wires for appropriate fracture patterns 2
- Open reduction with internal fixation for complex fractures 1
- External fixation (including needle cap fixators) for difficult situations with soft tissue compromise 5
The surgical goal is achieving anatomic reduction with stable fixation to allow early mobilization. 6
Rehabilitation Protocol
- Muscle strengthening exercises should begin early 2
- Long-term continuation of hand exercises is essential for optimal recovery 2
- Active mobilization prevents stiffness and rotational/axial deformities 3
- Patient education regarding pain management and rehabilitation exercises 2
Critical Pitfalls to Avoid
- Avoid prolonged static immobilization in plaster without joint mobilization, as this leads to interphalangeal joint stiffness 3
- Meticulous surgical technique is mandatory when operating, as variable complication rates following internal fixation remain problematic 6
- Immediate emergency care is necessary if the fractured digit appears blue, purple, or pale 2