What is the treatment approach for fractures in the distal vs proximal phalange location?

Treatment of Phalangeal Fractures: Distal vs Proximal Location

Proximal phalanx fractures require more aggressive surgical intervention for instability compared to distal phalanx fractures, which are more commonly managed conservatively, with the key distinction being that proximal fractures have higher risk of joint stiffness and rotational deformity that significantly impacts hand function. 1, 2

Initial Imaging Protocol

• Standard 3-view radiographic examination (PA, lateral, and oblique) is mandatory for all suspected phalangeal fractures 3, 1
• Adding an internally rotated oblique projection beyond the standard externally rotated oblique increases diagnostic yield for phalangeal fractures 3, 1
• CT without IV contrast should be obtained when radiographs are equivocal, particularly for evaluating intra-articular extension and displacement 1

Treatment Algorithm by Location

Proximal Phalanx Fractures

Surgical Indications (more stringent than distal fractures):

• Intra-articular displacement >3mm or any articular step-off 1
• Fractures involving >1/3 of the articular surface 1
• Interfragmentary gap >3mm 1
• Any joint instability or incongruity 1
• Unstable fracture patterns (transverse, oblique, comminuted) 2, 4

Surgical Options (in order of preference based on outcomes):

• Closed reduction and intramedullary screw fixation (CRIMEF) is superior for extra-articular proximal phalanx fractures, showing significantly faster return to work and better total active motion (TAM) compared to K-wires or plate fixation 5
• Dynamic external fixation is preferred for unstable intra-articular fractures of the proximal phalanx 1
• Multiple K-wire fixation is more predictable than single K-wire for displaced fractures, particularly unicondylar fractures 6
• Arthroscopic-assisted reduction for complex intra-articular fractures 1

Conservative Management:

• Functional dynamic treatment with dorsopalmar splint can achieve 86% full range of motion for stable fractures 4
• Position: wrist dorsiflexed 30°, metacarpophalangeal joints flexed 70-90° (intrinsic plus position) 4
• This approach achieves bony healing and mobility simultaneously, not sequentially 4

Distal Phalanx Fractures

More commonly managed conservatively:

• Most distal phalanx fractures can be treated successfully with nonoperative means 2
• Simple splinting is appropriate for nondisplaced or minimally displaced fractures 2
• Surgical intervention reserved for: large avulsion fragments requiring open reduction, significant articular incongruity, or concomitant soft tissue damage requiring repair 3, 2

Critical Post-Treatment Management

Early mobilization is paramount regardless of location:

• Active motion exercises should begin as soon as fracture stability allows to prevent joint stiffness, which is the most functionally disabling complication 1, 4
• For proximal phalanx fractures, active exercises in proximal and distal interphalangeal joints prevent rotational and axial deformities 4
• Short periods of post-operative immobilization (≤3 weeks) do not adversely affect final joint motion 6
• Radiographic follow-up at 3 weeks and at hardware removal to confirm healing 1

Location-Specific Complications

Proximal phalanx fractures carry higher complication risk:

• Joint stiffness occurs more frequently and is more functionally disabling than in distal fractures 1, 4
• Rotational and axial deformities are specific concerns for proximal fractures 4
• Malunion rates: 4 of 43 conservatively treated proximal fractures developed malunion 7
• Overall immobilization-related complications occur in 14.7% of cases 1

Distal phalanx fractures:

• Lower risk of significant functional impairment 2
• Mallet injuries can usually be managed with splinting alone 3

Critical Pitfalls to Avoid

• Never use simple splinting or buddy strapping for displaced proximal phalanx fractures—this produces the maximum poor results 7
• Avoid single K-wire fixation for displaced proximal phalanx fractures; multiple wires or screws provide better stability 6, 5
• Do not accept articular step-off >2mm in any phalangeal fracture, as this leads to post-traumatic arthritis 1
• Avoid excessive immobilization duration, which increases stiffness risk 1, 4
• For proximal fractures, failure to achieve anatomic reduction results in rotational deformity that compounds with each distal joint 4