What is the recommended treatment for a patient with a transverse fracture of the proximal aspect of the distal phalanx?

Treatment of Transverse Fracture of Proximal Aspect of Distal Phalanx

For transverse fractures of the proximal aspect of the distal phalanx, use removable splinting for 3-4 weeks if minimally displaced (<3mm), but proceed with surgical fixation if displacement exceeds 3mm, dorsal tilt exceeds 10°, or intra-articular involvement is present. 1

Initial Assessment and Classification

Immediately evaluate the fracture for:

• Displacement >3mm - this threshold determines surgical versus conservative management 1
• Dorsal tilt >10° - indicates need for surgical intervention 1
• Intra-articular extension - requires surgical fixation 1
• Open versus closed fracture - open fractures at this location (Seymour-type) require surgical debridement and fixation 2

Treatment Algorithm

For Minimally Displaced Fractures (<3mm displacement, <10° angulation):

• Apply removable splinting for 3-4 weeks as the primary treatment 1
• The splint should immobilize the distal interphalangeal joint while allowing proximal joints to move 1
• Initiate active finger motion exercises immediately for all uninvolved joints to prevent stiffness, which is the most functionally disabling complication 1
• Finger motion exercises do not adversely affect adequately stabilized fractures and are cost-effective interventions with significant impact on outcomes 1

For Displaced or Unstable Fractures (>3mm displacement, >10° tilt, or intra-articular):

• Surgical fixation with K-wires is indicated 1
• For open fractures (Seymour-type fractures in adults), perform open reduction and K-wire fixation after appropriate debridement 2
• The surgical approach should allow immediate mobilization of uninvolved joints 3

Follow-up Protocol

Structured radiographic evaluation is essential:

• Initial radiographs to confirm diagnosis and fracture pattern 1
• 3-week follow-up radiographs to assess healing progress 1
• Radiographs at time of immobilization removal to confirm adequate healing 1

Critical Management Points to Prevent Complications

Avoid over-immobilization - excessive immobilization leads to joint stiffness that becomes difficult to treat after fracture healing and may require multiple therapy visits or additional surgical intervention 1. This is particularly important in hand fractures where stiffness results from pain, swelling, and patient apprehension 1.

Instruct patients at the first encounter to move all uninvolved fingers regularly through complete range of motion 1. This intervention requires no pharmaceutical treatment or additional visits but provides significant impact on preventing the 14.7% rate of immobilization-related complications including skin irritation and muscle atrophy 1.

Common Pitfalls

• Missing intra-articular extension - always obtain adequate radiographic views to assess joint involvement, as this changes management from conservative to surgical 1
• Treating open fractures conservatively - Seymour-type fractures in adults require surgical management even if displacement appears minimal 2
• Immobilizing uninvolved joints - this leads to unnecessary stiffness; only immobilize the affected distal interphalangeal joint 1
• Failing to reevaluate patients with unremitting pain - persistent pain warrants reassessment for complications or inadequate reduction 1