Management of Comminuted Articular Fractures of the Distal Phalanx
Most comminuted articular fractures of the distal phalanx can be managed conservatively with rigid splint immobilization for 3-6 weeks, reserving surgery only for fractures with >3mm displacement, >1/3 articular surface involvement, palmar displacement, or interfragmentary gap >3mm. 1
Treatment Decision Algorithm
Conservative Management is Appropriate When:
- Minimal displacement (<3mm) 1
- Less than one-third of articular surface involved 2, 1
- No palmar displacement of the distal phalanx 2, 1
- Interfragmentary gap <3mm 2, 1
For these fractures, rigid immobilization with a splint for 3-6 weeks is the standard treatment 1. The American College of Radiology guidelines support conservative management for most distal phalanx fractures when displacement criteria are not met 2.
Surgical Intervention is Required When:
- Fracture fragment displacement >3mm 2, 1
- Involvement of more than one-third of the articular surface 2, 1
- Palmar displacement of the distal phalanx present 2, 1
- Interfragmentary gap >3mm 2, 1
Critical Early Mobilization Protocol
Active finger motion exercises must begin immediately after diagnosis for stable fractures or after adequate immobilization period to prevent stiffness, which is the most functionally disabling complication. 1 The American Academy of Orthopaedic Surgeons emphasizes that finger motion does not adversely affect adequately stabilized fractures regarding reduction or healing 1.
Specific Mobilization Timeline:
- For conservatively managed fractures: Begin active motion exercises after 3-6 weeks of rigid splinting 1
- For surgically managed fractures: Initiate range of motion exercises once adequate fixation is achieved 1
- Home exercise program is effective and should include complete range of motion exercises performed regularly 1
Imaging Requirements
Obtain at least 3-view radiographs (posteroanterior, lateral, and oblique) to properly evaluate fracture pattern, displacement, and articular involvement. 2, 1 Standard 2-view examinations are inadequate for detecting fractures and assessing displacement in finger injuries 2.
Common Pitfalls to Avoid
Failure to encourage early finger motion leads to severe, functionally disabling stiffness that is difficult to treat after fracture healing. 1 This complication is entirely preventable with appropriate early mobilization protocols 1.
Additional Pitfalls:
- Overlooking displacement or articular involvement can result in poor functional outcomes and may necessitate delayed surgical intervention 1
- Inadequate initial radiographic assessment with only 2 views may miss critical fracture characteristics that determine treatment 2
- Prolonged immobilization without motion exercises creates stiffness requiring multiple therapy visits or potentially surgical intervention 1
Follow-Up Monitoring
Monitor patients for: