Treatment of Distal Phalanx Fractures
Most distal phalanx fractures should be treated conservatively with protective splinting, as they typically heal well without surgery; however, displaced articular fractures—particularly volar base fractures with flexor tendon avulsion—require surgical fixation to restore function and prevent chronic instability. 1, 2
Initial Imaging Approach
- Obtain a minimum 3-view radiographic series (posteroanterior, lateral, and oblique) of the affected finger, as 2-view examinations are inadequate for detecting fractures 1
- An internally rotated oblique projection in addition to the standard externally rotated oblique increases diagnostic yield for phalangeal fractures 1
- For thumb fractures specifically, a 2-view examination is usually sufficient, though an oblique view slightly increases diagnostic yield 1
Treatment Algorithm Based on Fracture Pattern
Non-Displaced Shaft and Tuft Fractures (Most Common)
- Conservative management is appropriate for most distal phalanx fractures, particularly those sustained in crushing injuries 2
- The fracture itself rarely needs specific treatment; focus on managing surrounding soft tissue injuries (nail bed lacerations, subungual hematomas) 2
- Protective splinting for 3-4 weeks allows adequate healing 3, 2
Displaced or Comminuted Shaft/Neck Fractures
- These fractures are prone to symptomatic nonunion manifesting as pain and instability 4
- Consider early surgical fixation with interfragmentary screw fixation for displaced or comminuted fractures of the shaft or neck, as this achieves union in all cases with minimal morbidity 4
- Open reduction and screw fixation results in fracture union at approximately 4 months with return to normal finger function 4
Volar (Palmar) Articular Base Fractures
- Surgical treatment is mandatory for displaced volar articular fractures, as these represent avulsion of the flexor digitorum profundus tendon insertion 2
- These injuries require careful surgical replacement and fixation to restore tendon function 2
- Transosseous indirect reduction is a minimally invasive technique that provides stable fixation and facilitates early recovery 5
Dorsal Articular Fractures (Mallet Fractures)
- Nonoperative treatment is preferred for mallet fractures despite some controversy in the literature 2
- Continuous splinting in extension for 6-8 weeks is the standard approach 2
- Radiographs are usually sufficient for evaluation of osseous mallet injuries 1
- Large fracture fragments may require open reduction and internal fixation if they involve a substantial portion of the articular surface 1
Key Surgical Indications
Proceed with operative fixation when:
- Articular incongruity is present (>2mm step-off to prevent osteoarthritis) 1
- Volar base fractures with flexor tendon avulsion 2
- Displaced or comminuted shaft/neck fractures at risk for symptomatic nonunion 4
- Concomitant soft tissue damage requiring surgical exploration 3
- Unstable fracture patterns that cannot maintain reduction 3
Critical Pitfalls to Avoid
- Failure to obtain adequate radiographic views (minimum 3 views) leads to missed fractures and underestimation of displacement 1
- Treating all distal phalanx fractures conservatively without recognizing volar base fractures that require surgery 2
- Delayed recognition of symptomatic nonunion in displaced shaft fractures—early fixation prevents chronic pain and instability 4
- Inadequate soft tissue management in crushing injuries, which is often more important than the fracture itself 2