What is the treatment for a pediatric or adolescent patient with a non-displaced Salter Harris 3 fracture at the index finger middle phalanx?

Treatment of Non-Displaced Salter-Harris Type 3 Fracture of the Index Finger Middle Phalanx

Immobilize the finger with a protective splint (buddy taping or aluminum splint) for 3-4 weeks, followed by early range of motion exercises. This conservative approach is appropriate for non-displaced intra-articular physeal fractures of the phalanx and yields excellent functional outcomes with minimal complications.

Rationale for Conservative Management

Non-displaced phalangeal fractures, including Salter-Harris type 3 injuries, should be managed with splint immobilization alone. 1 The key principle is that non-displaced fractures maintain articular congruity and physeal alignment, making surgical intervention unnecessary and potentially harmful.

Immobilization Protocol

• Duration: Immobilize for 3-4 weeks based on clinical and radiographic healing 1, 2
• Method: Use buddy taping to the adjacent finger or a protective aluminum splint that allows some controlled motion 3
• Position: Splint in the intrinsic-plus position (slight flexion at MCP joint, extension at PIP/DIP joints) to prevent joint stiffness

Critical Monitoring Requirements

Close radiographic follow-up is essential between days 7-14 post-injury to detect any loss of reduction. 4 This is the critical window when displacement can occur:

• Obtain repeat radiographs at 7-10 days post-injury
• Assess for any displacement or angulation that developed during immobilization
• If displacement occurs (>10° angulation or any articular step-off), consider closed reduction with percutaneous pinning 2, 5

Why Surgery is NOT Indicated

The evidence strongly supports conservative management for non-displaced fractures:

• Lower complication rates: Conservative treatment shows complication rates of 20% versus 37% with surgical fixation 5
• Excellent functional outcomes: Non-surgical management achieves mean Michigan Hand Outcomes Questionnaire scores of 97.2-99.3 5
• Minimal rotational deformity risk: Only 0.93% rate of clinically significant rotational malalignment with conservative treatment 2
• Avoids surgical risks: Surgery introduces risks of infection, pin tract complications, physeal damage, and stiffness 1, 5

Special Considerations for Salter-Harris Type 3

Since this is an intra-articular fracture involving the growth plate:

• Articular congruity is paramount: Any step-off >2mm at the joint surface requires anatomic reduction 1
• Growth disturbance risk: While present, non-displaced SH3 fractures have minimal risk when properly immobilized 4
• Confirm true non-displacement: Ensure AP, lateral, and oblique radiographs show <2mm displacement and no articular incongruity

Rehabilitation Protocol

After 3-4 weeks of immobilization 1, 3:

• Begin active range of motion exercises immediately upon splint removal
• Avoid passive stretching for an additional 2 weeks
• Most patients achieve full range of motion within 2-4 weeks post-immobilization 3
• Return to contact sports at 6-8 weeks if full painless motion achieved

Red Flags Requiring Surgical Intervention

Convert to closed reduction and percutaneous pinning if 2, 5:

• Any displacement develops on follow-up radiographs (>10° angulation)
• Articular step-off >2mm
• Rotational malalignment detected clinically (scissoring of digits with flexion)
• Inability to maintain reduction with immobilization alone