How do you manage a longitudinally oriented comminuted fracture of the fifth middle phalanx extending to the DIP (Distal Interphalangeal) and PIP (Proximal Interphalangeal) joints?

Management of Longitudinally Oriented Comminuted Fifth Middle Phalanx Fracture

This complex intra-articular fracture involving both the PIP and DIP joints requires immediate hand surgery referral, as longitudinally oriented comminuted fractures extending into both joints are highly unstable and typically require surgical intervention with dynamic external fixation or specialized reconstruction techniques to preserve joint function and prevent permanent disability.

Initial Assessment and Imaging

• Obtain three-view radiographs immediately (posteroanterior, lateral, and oblique) to fully characterize the fracture pattern, degree of comminution, articular involvement, and joint subluxation 1
• Assess for rotational deformity, which is a critical indicator for surgical intervention even in seemingly minor fractures 1
• Consider CT imaging if surgical planning is needed to precisely map the fracture fragments and joint surface involvement 2

Immediate Splinting Prior to Referral

• Apply a ulnar gutter splint that immobilizes the fourth and fifth digits together, extending from the mid-forearm to beyond the fingertip 1
• Position the hand with the wrist in 20-30 degrees of extension, the metacarpophalangeal joint in 70-90 degrees of flexion, and the interphalangeal joints in 10-15 degrees of flexion (the "safe position") to prevent ligamentous contracture 1
• Buddy tape the fifth finger to the fourth finger within the splint for additional stability 1
• This is a temporizing measure only—definitive treatment requires surgical consultation 2, 3

Why This Fracture Pattern Requires Surgical Referral

Longitudinally oriented comminuted fractures involving both the PIP and DIP joints represent "pilon-type" injuries that are inherently unstable and cannot be adequately managed with simple splinting alone. The specific challenges include:

• Longitudinal instability with joint subluxation that cannot be maintained with closed reduction 2
• Comminution of the articular surface affecting both joints, which requires precise anatomic restoration to prevent post-traumatic arthritis 3
• High risk of stiffness and permanent loss of function if not treated with early mobilization protocols, which require surgical stabilization first 2

Surgical Treatment Options (For Specialist)

The hand surgeon will likely consider one of these approaches:

• Dynamic external fixation (distraction apparatus) is the preferred method for comminuted intra-articular fractures with longitudinal instability, allowing early range of motion while maintaining joint alignment 2, 4
• Volar plate arthroplasty or volar plate draping may be considered if the fracture is not reconstructable, particularly for severely comminuted proximal interphalangeal joint injuries 5
• Hemihamate arthroplasty with oblique osteotomy can reconstruct the articular surface when >30-50% of the volar articular surface shows comminuted fracture not amenable to internal fixation 3
• Open reduction with K-wires and external fixation using specialized systems (such as the Ichi-Fixator) for comminuted intra-articular fractures 4

Critical Pitfalls to Avoid

• Do not attempt closed reduction and simple buddy taping for this fracture pattern—longitudinally oriented comminuted fractures with bi-articular involvement are inherently unstable and will lose position 2
• Do not delay referral beyond 24-48 hours, as early surgical intervention (ideally within 7-10 days) is associated with better functional outcomes in complex intra-articular fractures 3
• Do not immobilize in full extension, as this increases the risk of extensor tendon adhesions and permanent stiffness; maintain slight flexion at the interphalangeal joints 1
• Do not underestimate the complexity based on initial radiographs alone—longitudinal fracture patterns often have more extensive articular damage than apparent on plain films 2

Expected Timeline

• Immediate: Splinting and referral to hand surgery within 24-48 hours 2, 3
• Surgical intervention: Typically performed within 7-10 days of injury 3
• External fixation duration: Usually 4-6 weeks, followed by progressive range of motion exercises 2, 4
• Recovery: Expect 3-6 months for functional recovery, with some patients achieving full range of motion 5, 2