What is the treatment for a mildly displaced comminuted fracture of the small finger proximal phalanx?

Treatment of Mildly Displaced Comminuted Proximal Phalanx Fracture of the Small Finger

For a mildly displaced comminuted fracture of the small finger proximal phalanx, initial treatment should consist of closed reduction (if needed to achieve acceptable alignment) followed by immobilization in an intrinsic-plus position with a dorsopalmar splint for 3-4 weeks, combined with immediate active finger motion exercises of the interphalangeal joints to prevent stiffness. 1, 2, 3

Initial Management Approach

Reduction and Alignment Goals

• Accept minimal displacement and angulation of less than 10 degrees, as these can be managed non-operatively with buddy taping or splinting 4
• Larger angulations, significant displacement, or malrotation require closed reduction or surgical intervention 4
• The key threshold is whether acceptable alignment can be achieved and maintained with closed methods 2

Immobilization Technique

• Use a dorsopalmar plaster splint that immobilizes the wrist in 30 degrees of dorsiflexion and the metacarpophalangeal joint in 70-90 degrees of flexion (intrinsic-plus position) 3
• This position places the extensor aponeurosis under tension, which covers two-thirds of the proximal phalanx and provides firm splinting of the fracture 3
• Maintain immobilization for 3-4 weeks until clinical healing is evident 1, 3
• The interphalangeal joints should remain free to move during this period 3

Critical Early Intervention: Active Motion Protocol

Initiate active finger motion exercises of the proximal and distal interphalangeal joints immediately, even while the metacarpophalangeal joint remains immobilized. 1, 3

• Hand stiffness is one of the most functionally disabling complications of proximal phalanx fractures and becomes extremely difficult to treat after fracture healing 1
• Active exercises in the interphalangeal joints prevent mobility limitations and subsequent rotational and axial deformities 3
• This approach achieves bony healing and free mobility simultaneously rather than sequentially 3
• In one series of 78 proximal phalanx fractures treated with this functional approach, 86% showed full range of motion at follow-up, with only 14% having minor limitations 3

Pain Management

• Start with regular paracetamol (acetaminophen) as first-line therapy unless contraindicated 1
• Use opioids cautiously, particularly if renal dysfunction is present 1
• NSAIDs should be used with caution as they are relatively contraindicated in many patients 1

Radiographic Surveillance

• Obtain radiographs at 3 weeks post-injury to confirm the fracture remains acceptably aligned 1
• Repeat imaging at cessation of immobilization (typically 3-4 weeks) to document healing 1
• Monitor for loss of reduction during the immobilization period, which would necessitate surgical intervention 2

Surgical Indications

Consider surgical fixation if:

• The fracture cannot be reduced to acceptable alignment (>10 degrees angulation, significant displacement, or malrotation) 2, 4
• Loss of reduction occurs during the immobilization period 2
• The comminution is so severe that closed methods cannot maintain stability 2

For comminuted proximal phalanx fractures requiring surgery, plate fixation is the preferred method, though external fixation systems can be considered for severely comminuted intra-articular fractures 5, 2

Common Pitfalls to Avoid

• Prolonged rigid immobilization of interphalangeal joints: This is the primary cause of finger stiffness and poor functional outcomes 1, 3
• Failure to achieve intrinsic-plus position: Improper splinting position will not provide adequate fracture stability and increases risk of displacement 3
• Inadequate patient education: Patients must understand the critical importance of active interphalangeal joint exercises from day one to prevent stiffness 1
• Missing rotational deformity: Always assess for malrotation by having the patient make a fist—all fingers should point toward the scaphoid tubercle 4

Follow-Up Protocol

• Re-evaluate at 3 weeks with radiographs to confirm maintained alignment 1
• Remove immobilization at 3-4 weeks once clinical healing is evident 1, 3
• Continue active motion exercises until full range of motion is restored 3
• Patients should return immediately if symptoms worsen or pain increases, suggesting loss of reduction 1