Management of Intra-articular Middle Phalanx Fractures
For intra-articular fractures of the middle phalanx, operative intervention is indicated when there is >2 mm articular step-off, joint subluxation/dislocation, or instability, while stable fractures with minimal displacement can be managed conservatively with buddy taping and immediate mobilization. 1, 2, 3
Initial Diagnostic Approach
- Obtain a minimum 3-view radiographic examination (posteroanterior, lateral, and oblique) as the standard initial imaging, since 2-view examinations miss fractures 1, 4
- The oblique view is critical for detecting phalangeal fractures that may be missed on standard views 1
- If radiographs are equivocal but clinical suspicion remains high, place the finger in a splint and repeat radiographs in 10-14 days, or consider CT without IV contrast for better characterization of intra-articular extension 1, 4
Key Fracture Characteristics for Surgical Decision-Making
The most reliable and clinically useful features that guide operative vs. non-operative management include:
- Articular step or gap ≥2 mm - this is the most strongly associated factor with need for surgery and has substantial interobserver agreement (kappa 0.73) 1, 2
- Joint subluxation or dislocation - highly reliable assessment (kappa 0.72) and strongly predicts need for operative treatment 2
- Joint instability - unstable fractures are strongly associated with surgical intervention 2
- Percentage of articular surface involved has moderate reliability (ICC 0.67) 2
Common pitfall: Comminution and number of fracture fragments have only fair-to-moderate interobserver agreement, making them less reliable for surgical decision-making 2
Treatment Algorithm
Conservative Management (Non-operative)
Indications:
- Stable fractures with <2 mm articular displacement 1, 3
- Minimal angulation (<10 degrees) 3
- No subluxation or dislocation 2
- Stable joint after closed reduction 5
Treatment protocol:
- Buddy taping to adjacent finger with immediate mobilization 6, 3
- Splinting for 4-6 weeks for uncomplicated middle phalanx fractures 3
- This approach yields high patient satisfaction, full flexion recovery in most cases, and rare malrotation requiring surgery 6
Operative Management
Indications:
- Articular step-off or gap >2 mm 1, 2
- Joint subluxation or dislocation present 2
- Unstable fractures that cannot maintain reduction 2, 7
- Large angulation or displacement 5, 3
- Malrotation 5, 3
Operative options include:
- Extension block pinning 2
- External fixation 2
- Open reduction and internal fixation 5, 2
- Volar plate arthroplasty 2
- Hemihamate autograft arthroplasty 2
Important caveat: There is substantial agreement among surgeons on whether to operate (kappa 0.69), but only fair agreement on which specific operative technique to use (kappa 0.34), indicating significant variation in surgical approaches 2. The systematic review evidence shows only level III-IV studies with high complication rates across all operative techniques 7.
Referral Criteria
Prompt referral to orthopedic or hand surgery is needed for:
- Unstable fractures or those with rotation 5
- Irreducible dislocations 5
- Any fracture meeting operative criteria above 5, 3
Expected Outcomes
- Conservative management with buddy taping shows excellent return of grip strength and good function, though some ongoing pain and stiffness may persist 6, 7
- Operative fixation resulting in <2 mm residual articular step-off is necessary to avoid long-term osteoarthritis 1
- All operative techniques have high complication rates, and internal fixation can paradoxically lead to decreased finger mobility despite exact fracture reduction 6, 7