Management of 3mm Avulsion Fracture at Base of Proximal Phalanx in 12-Year-Old
This 3mm avulsion fracture at the base of the proximal phalanx requires immediate orthopedic referral for surgical fixation, as conservative management of these injuries consistently fails. 1
Critical Evidence Supporting Surgical Management
The most definitive evidence comes from a prospective study specifically examining avulsion fractures at the base of proximal phalanges: all eight fractures treated conservatively failed to unite and subsequently required surgery, while all 25 patients treated with primary internal fixation achieved excellent results with full range of movement within 3 weeks. 1
This represents a 100% failure rate for conservative management versus 100% success rate for surgical intervention in this exact fracture pattern. 1
Surgical Approach and Technique
The volar A1 pulley approach is the preferred surgical technique for these fractures, providing direct access to the volar-located fragment and allowing anatomic restoration of the articular surface. 2
Internal fixation using a single lag screw through the palmar approach achieves optimal outcomes. 1
This approach consistently achieves:
Immediate Management Prior to Orthopedic Referral
Apply ice-water mixture for 10-20 minutes with a thin towel barrier to reduce swelling. 3
Splint the finger in the position found until proper orthopedic evaluation—do not attempt manual straightening. 3
Maintain uninterrupted immobilization, as even brief splint removal can restart the healing timeline. 3
Provide appropriate analgesia (topical NSAIDs preferred over oral for safety in pediatric patients). 3
Why Conservative Management Fails
The biomechanical forces at the base of the proximal phalanx, combined with collateral ligament attachments, prevent adequate healing without surgical stabilization. 1 The 100% nonunion rate with conservative treatment in the definitive study makes this a clear-cut surgical indication. 1
Post-Operative Rehabilitation
Begin active finger motion exercises of the PIP and MCP joints immediately while keeping the DIP splinted to prevent stiffness. 3
Patients typically achieve full range of motion within 3 weeks post-operatively. 1
Monitor for unremitting pain during immobilization, which warrants immediate re-evaluation. 3
Key Pitfall to Avoid
Do not attempt conservative management with buddy taping or casting for this injury. While base fractures of the fifth proximal phalanx may be managed conservatively 4, avulsion fractures at the base of any proximal phalanx have demonstrated universal failure with non-operative treatment. 1 The distinction is critical: avulsion fractures involve ligamentous attachments and require surgical fixation, whereas other base fracture patterns may heal with immobilization alone.