Initial Treatment of Multiple Phalange Fractures
Most phalangeal fractures should be treated non-operatively with immediate pain control, buddy taping or splinting in the intrinsic-plus position (wrist extended 30°, metacarpophalangeal joints flexed 70-90°), and early range-of-motion exercises starting within days to prevent stiffness. 1, 2
Immediate Management Approach
Initial Assessment and Stabilization
- Provide appropriate analgesia for pain control 3
- Apply a sling or splint for comfort only, not rigid immobilization 3
- Begin immediate finger and hand motion exercises for uninjured digits 3
- Obtain standard radiographs (posteroanterior, lateral, and oblique views) to characterize fracture pattern 4
Non-Operative Treatment (Preferred for Most Cases)
The vast majority of phalangeal fractures can be treated successfully without surgery. 1
Splinting Technique
- Use dorsopalmar plaster splint with the wrist dorsiflexed 30° and metacarpophalangeal joints flexed 70-90° (intrinsic-plus position) 5
- This position tautens the extensor aponeurosis, providing firm fracture splinting while allowing interphalangeal joint motion 5
- Buddy tape adjacent fingers for additional stability 2
Early Mobilization Protocol
- Start active range-of-motion exercises in the proximal and distal interphalangeal joints within the first few days 2, 5
- Early motion prevents stiffness (the most common complication), improves healing, and hastens return to function 2
- Continue splinting for only 3 weeks if clinically healed at that point, rather than the traditional 5 weeks 6
Surgical Indications (Minority of Cases)
Surgery is reserved for specific situations where non-operative treatment will not restore function 1, 7:
- Unstable fracture patterns that cannot maintain reduction
- Articular incongruity requiring anatomic restoration
- Concomitant soft tissue damage requiring repair
- Open fractures with significant contamination
- Multiple fractures preventing adequate splinting
Surgical Principles When Indicated
- Achieve anatomic reduction with stable fixation 7
- Use meticulous surgical technique with careful soft tissue handling 1
- Initiate early postoperative mobilization within the first postoperative days 3, 7
- Restrict above-chest level activities until fracture healing is evident 3
Critical Pitfalls to Avoid
- Prolonged immobilization is the primary cause of stiffness - function, not radiographic appearance, should guide treatment decisions 2
- Overly aggressive physical therapy in early postoperative period may cause fixation failure 8
- Unremitting pain during follow-up warrants reevaluation for complications 4
- X-rays demonstrate anatomy but not function - clinical assessment of motion and stability is paramount 2
Follow-Up Protocol
- Reassess at 3 weeks for clinical healing (absence of tenderness, ability to move without pain) 6
- If clinically healed at 3 weeks, discontinue immobilization and advance to progressive strengthening 6
- Continue balance training and fall prevention long-term in elderly patients 3
- Monitor for complications including stiffness, malunion, or rotational deformities 5