Treatment of Oblique Fracture Through the Distal Metaphysis of the Middle Phalanx
This fracture should be treated with splint immobilization of the affected finger for 3-4 weeks, with early active motion exercises for non-immobilized joints, provided the fracture is stable and non-displaced. 1, 2
Initial Assessment and Imaging
- Confirm fracture stability and alignment with standard 3-view radiographic examination (PA, lateral, and oblique views) before initiating treatment 1
- Assess for displacement >3mm, angulation >10°, or rotational deformity, as these indicate instability requiring surgical consultation 2, 3
- Evaluate for articular involvement at the proximal interphalangeal (PIP) joint, which may alter treatment approach 4
Treatment Algorithm
For Non-Displaced or Minimally Displaced Fractures:
Splinting Protocol:
- Apply a splint that immobilizes the middle phalanx while allowing motion at adjacent joints (DIP and PIP) to prevent stiffness 2, 3
- Duration of immobilization should be 3-4 weeks (average 24 days) 2, 5
- Begin active finger motion exercises immediately for non-immobilized joints to prevent stiffness 2, 5
Critical Point: Finger motion does not adversely affect adequately stabilized phalangeal fractures, and early mobilization is essential to prevent the most functionally disabling complication—joint stiffness 5, 6
Indications for Orthopedic Referral and Surgical Treatment:
Refer immediately if any of the following are present:
- Displacement >3mm 2, 3
- Dorsal angulation >10° 2, 3
- Rotational deformity (assess by having patient make a fist—all fingers should point toward scaphoid) 6
- Articular surface involvement with step-off or incongruity 4, 6
- Unstable fracture pattern that cannot maintain reduction with splinting 4, 6
Surgical options for unstable fractures include:
- Internal fixation with 1.5-2mm screws for oblique fractures, which provides stable fixation allowing early mobilization 7
- Transosseous indirect reduction techniques for articular involvement 8
Follow-Up Protocol
Radiographic monitoring:
- Repeat radiographs at 3 weeks to assess healing and confirm maintained alignment 2, 3
- Additional imaging at cessation of immobilization (3-4 weeks) to confirm adequate healing before discontinuing splint 1, 2
Rehabilitation:
- Progressive range of motion exercises after splint removal 6
- Most patients return to work within 6 weeks for conservatively managed fractures 7
Common Pitfalls and Complications
Avoid these errors:
- Over-immobilization leading to joint stiffness (occurs in approximately 14.7% of cases with prolonged immobilization) 2, 5
- Failure to recognize rotational deformity on initial examination 6
- Missing articular involvement that requires surgical intervention 4
- Inadequate follow-up radiographs allowing loss of reduction to go undetected 1, 2
Expected complications:
- Post-traumatic arthritis if articular surface is involved 2
- PIP joint flexion contracture of 10-30° is the most common complication even with appropriate treatment 7
- Skin irritation and muscle atrophy from immobilization 2, 5
The key to successful treatment is achieving and maintaining anatomic alignment while minimizing immobilization time through early protected motion of adjacent joints. 6, 7