What is the management of an avulsion fracture of the middle phalanx of the 4th finger in a pediatric patient?

Management of Avulsion Fracture of the Middle Phalanx, 4th Finger in a Child

Begin with standard 3-view radiographs (PA, lateral, and oblique) of the injured finger to characterize the fracture pattern, assess articular involvement, and determine stability—this imaging is essential before any treatment decision. 1

Initial Imaging and Assessment

• Obtain posteroanterior, lateral, and internally rotated oblique radiographs of the 4th finger to maximize detection of phalangeal fractures 1
• Standard 3-view examination shows most fractures and dislocations of the phalanges 1
• Assess specifically for:
  • Size of the avulsed fragment (particularly if ≥1/3 of articular surface is involved) 2
  • Palmar displacement of the distal phalanx 1
  • Interfragmentary gap (>3 mm indicates instability) 1, 2
  • Rotational deformity or coronal malalignment in the digital cascade 3, 4

Treatment Algorithm Based on Fracture Characteristics

Non-operative Management (Most Common)

For stable, nondisplaced avulsion fractures or those with <1/3 articular involvement and no subluxation, treat with splint immobilization and close monitoring. 3, 4

• Immobilize with appropriate splinting for 4-6 weeks 5
• Buddy tape to adjacent finger for additional stability 5
• Begin active range of motion exercises of the PIP and MCP joints immediately while keeping the injured joint splinted to prevent stiffness 2
• Critical caveat: Close monitoring is essential to ensure maintenance of fracture reduction, as pediatric fractures can displace during healing 3, 4

Operative Management Indications

Refer immediately for surgical consultation if any of the following are present: 1, 6

• Avulsion fragment involving ≥1/3 of the articular surface 1, 2
• Palmar displacement of the distal phalanx 1
• Interfragmentary gap >3 mm 1, 2
• Volar subluxation on lateral radiographs (absolute surgical indication) 2
• Unstable fracture that displaces after closed reduction 6, 3
• Rotational malalignment that cannot be corrected with closed reduction 3, 4

Surgical Approach When Indicated

• Closed reduction and percutaneous pinning is preferred for unstable displaced phalanx fractures in children 3, 4
• Open reduction with internal fixation may be necessary for large avulsion fragments, particularly using hook plate technique for small osseous fragments attached to stabilizing structures 7
• Surgery aims to restore joint stability and articular congruity, which are primary determinants of long-term outcome 6

Key Clinical Pitfalls to Avoid

• Never delay radiographs, as this can lead to unreliable exclusion of fractures requiring surgery 2
• Do not underestimate small avulsion fragments with subluxation—even small fragments with volar subluxation require surgical referral 2
• Avoid intermittent splint removal during healing, as this restarts the healing timeline 2
• In children aged 10-14 years (peak incidence), maintain high suspicion for physeal involvement, as Salter-Harris type II fractures of the proximal phalanx are most common 3, 4
• Younger children with crush injuries may have associated soft tissue damage requiring additional evaluation 3, 4

Follow-up Protocol

• Re-evaluate immediately if unremitting pain develops during immobilization 2
• Serial radiographs at 1-2 weeks to confirm maintenance of reduction in conservatively managed fractures 3, 4
• Monitor for signs of malunion, rotational deformity, or joint stiffness throughout healing 6