What is the best treatment for a 10-year-old patient with a non-displaced avulsion fracture at the base of the index finger middle phalanx?

Treatment of Non-Displaced Avulsion Fracture at the Base of the Index Finger Middle Phalanx in a 10-Year-Old

For a non-displaced avulsion fracture at the base of the middle phalanx in a 10-year-old, immobilize with splinting and buddy taping to the adjacent finger, allowing early mobilization within 3-4 weeks. 1

Initial Management Approach

Splint immobilization is the primary treatment for non-displaced phalangeal fractures in children. 1 The key is to assess stability and ensure proper alignment of the digital cascade:

• Check for rotational deformity by having the child make a fist—all fingers should point toward the scaphoid tubercle 2
• Assess for coronal plane malalignment by examining the finger from the side 1
• Confirm non-displacement on anteroposterior, lateral, and oblique radiographs 2

Specific Treatment Protocol

Immobilize the proximal interphalangeal (PIP) joint in 15-30 degrees of flexion using a dorsal or volar splint for 3-4 weeks. 2, 1 After initial splinting:

• Buddy tape to the middle finger to provide support while allowing controlled motion 2, 3
• Begin gentle range-of-motion exercises at 3-4 weeks to prevent stiffness 1
• Monitor closely with repeat radiographs at 7-10 days to ensure the fracture remains non-displaced 1

Critical Distinction: Dorsal vs. Volar Avulsion

The location of the avulsion fragment matters significantly for prognosis 4:

• Dorsal avulsion fractures (involving the central slip insertion) risk boutonnière deformity if the fragment is large or displaced, requiring surgical referral 4
• Volar avulsion fractures are typically more stable and respond well to conservative management 4

Since your case is non-displaced, conservative treatment is appropriate regardless of location 4, 1.

Pediatric-Specific Considerations

Children aged 10 years have significant remodeling potential, which favors conservative management 1:

• The physis (growth plate) is weaker than surrounding ligaments, making physeal injuries more common than ligamentous injuries 1
• Salter-Harris type II fractures are most common in this age group and typically heal well with immobilization 1
• Accept up to 10 degrees of angulation in non-displaced fractures, as remodeling will correct minor deformities 2

Common Pitfalls to Avoid

Do not over-immobilize. Prolonged rigid splinting beyond 4 weeks leads to joint stiffness and decreased function 1, 3:

• Avoid immobilizing the metacarpophalangeal (MCP) joint unless absolutely necessary 2
• Start buddy taping and gentle motion by week 3-4 to prevent permanent stiffness 3
• Surgical fixation in stable pediatric fractures often results in worse functional outcomes than conservative treatment 3

When to Refer for Surgery

Immediate orthopedic referral is indicated if 4, 2, 1:

• Displacement occurs or increases on follow-up radiographs
• Angulation exceeds 10 degrees
• Rotational malalignment is present
• The fracture involves >25-30% of the articular surface (though this is less common in true avulsion fractures)
• Dorsal avulsion fragments are large enough to compromise central slip function

Follow-Up Protocol

Schedule radiographic follow-up at 7-10 days, then at 3-4 weeks 1:

• Assess for maintenance of reduction at first follow-up
• Confirm healing and begin weaning from splint at 3-4 weeks
• Full return to sports typically occurs at 6-8 weeks once full range of motion is restored 1