From the Guidelines
A displaced fracture of the base of the second proximal phalanx typically requires prompt orthopedic evaluation and treatment, with initial management including immobilization with a finger splint and potential surgical fixation depending on fracture severity and displacement. The management of this type of fracture is crucial to prevent long-term morbidity and mortality, and to maintain quality of life by preserving hand function and grip strength. According to the American College of Radiology 1, radiography is always indicated as the initial imaging for suspected acute hand and wrist trauma, and a standard 3-view radiographic examination of the hand shows most fractures and dislocations of the metacarpals and phalanges.
For phalangeal injuries, some centers include a PA examination of the entire hand, whereas others limit the examination to the injured finger 1. An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures 1. Initial treatment includes immobilization with a finger splint in the "safe position" (slight flexion at the MCP joint) to prevent stiffness and deformity. Apply ice for 15-20 minutes every 2-3 hours during the first 48 hours to reduce swelling, and elevate the hand above heart level. Take acetaminophen (500-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours) for pain control.
Definitive treatment depends on fracture severity and displacement; options include:
- Closed reduction with splinting/casting for 3-4 weeks
- Surgical fixation with pins, screws, or plates for severely displaced or unstable fractures Physical therapy is crucial after immobilization to restore range of motion and strength. This fracture requires proper treatment because the proximal phalanx forms part of two important joints (MCP and PIP), and improper healing can lead to permanent stiffness, malrotation, or arthritis, significantly affecting hand function and grip strength. The American College of Radiology guidelines 1 provide the most recent and highest quality evidence for the management of acute hand and wrist trauma, and should be followed to ensure optimal outcomes.
From the Research
Displaced Fracture of Base of Second Proximal Phalanx
- A displaced fracture of the base of the second proximal phalanx can be managed operatively or non-operatively, depending on the severity of the injury and the patient's overall condition 2, 3.
- Non-operative management may be suitable for stable, non-displaced or minimally displaced fractures, and can involve splint immobilization and early mobilization 4, 5.
- Operative management, such as closed reduction and percutaneous pinning, may be necessary for unstable, displaced fractures to restore anatomy and impart stability, allowing for early motion 2, 6.
- The choice of fixation method can range from percutaneous pinning to open reduction and internal fixation, and the type of fixation used can affect the outcome of the treatment 2, 3.
- Excellent or good outcomes can be achieved with K-wire pinning or conservative management, but current evidence is limited for plate or intramedullary screw fixation 2.
- It is essential to assess the digital cascade for signs of rotational deformity and/or coronal malalignment, and to use plain radiographs to confirm the diagnosis of a phalangeal fracture 4.