What is the initial treatment for a closed, nondisplaced proximal phalanx fracture in an otherwise healthy adult?

Initial Treatment of Closed, Nondisplaced Proximal Phalanx Fracture

For a closed, nondisplaced proximal phalanx fracture in a healthy adult, treat with dynamic functional immobilization using a dorsopalmar splint in the intrinsic-plus position (wrist dorsiflexed 30°, metacarpophalangeal joint flexed 70-90°) while allowing immediate active range of motion exercises at the interphalangeal joints. 1

Immobilization Technique

• Apply a dorsopalmar plaster splint that immobilizes only the wrist and metacarpophalangeal joint, leaving the proximal and distal interphalangeal joints free for immediate active motion 1
• Position the wrist in 30° of dorsiflexion and the metacarpophalangeal joint in 70-90° of flexion (intrinsic-plus position), which creates tension in the extensor aponeurosis that covers two-thirds of the proximal phalanx and provides firm fracture splinting 1
• This functional treatment approach achieves bony healing and free mobility simultaneously rather than sequentially 1

Pain Management Protocol

• Administer regular paracetamol (acetaminophen) immediately as first-line analgesia unless contraindicated 2, 3
• Add opioid analgesia cautiously with reduced dosing, particularly since approximately 40% of fracture patients have moderate renal dysfunction requiring dose adjustment 2, 3
• Avoid NSAIDs entirely until renal function is confirmed, as they are relatively contraindicated due to high prevalence of renal dysfunction in fracture populations 2, 3

Active Mobilization Strategy

• Begin active exercises in the proximal and distal interphalangeal joints immediately to prevent stiffness and subsequent rotational or axial deformities 1
• The goal is to maintain gliding of flexor and extensor tendons throughout the healing process 4, 5
• In a follow-up study of 78 proximal phalanx fractures treated with this dynamic functional method, 86% achieved full range of motion with all fractures consolidating without delayed union or pseudarthrosis 1

Expected Outcomes and Follow-up

• Fracture consolidation typically occurs within 6 weeks with this treatment approach 4
• When properly executed, 86% of patients achieve full range of motion, with only 14% showing minor limitations (extension lag up to 20° in the proximal interphalangeal joint or fingertip-palm distance of 1.1 cm) 1
• No cases of delayed healing or pseudarthrosis should occur with appropriate functional treatment 1

Critical Pitfalls to Avoid

• Do not use static plaster immobilization that includes the interphalangeal joints, as this traditional approach leads to joint stiffness and requires sequential rather than simultaneous achievement of healing and mobility 1
• Do not delay pain assessment and management while focusing on immobilization, as early effective analgesia is crucial 2, 3
• Do not prescribe NSAIDs without checking renal function first, given the extremely high rates of renal impairment in fracture patients 2, 3
• Do not use standard opioid dosing in elderly patients without dose reduction, particularly in those with renal dysfunction 2, 3

Alternative Consideration for Dorsally Angulated Fractures

• If the fracture demonstrates dorsal angulation after closed reduction, consider using a reversed dynamic extension splint (such as Roylan Sof-Stretch) to maintain reduction while still allowing joint motion 6
• This approach has demonstrated successful bony union with very good function at both the metacarpophalangeal and proximal interphalangeal joints 6