Management of Minimally Displaced Intraarticular Fracture of Middle Phalanx at Volar Base
Treat this fracture with removable splinting for 3-4 weeks combined with immediate active finger motion exercises, and obtain mandatory follow-up radiographs at 3 weeks to detect any delayed displacement that would require surgical conversion. 1
Initial Treatment Protocol
Removable splinting is the definitive treatment for truly minimally displaced intraarticular fractures at the volar base of the middle phalanx. 1 This approach allows for:
- Immediate active finger motion exercises to prevent joint stiffness, which is one of the most functionally disabling complications of phalangeal fractures 1, 2
- Splint immobilization for 3-4 weeks total duration 1, 2
- The splint should be removable to allow for dressing changes and radiographic evaluation 3
Critical Imaging Requirements
Standard 3-view radiographic examination (PA, lateral, and oblique) is essential for initial diagnosis, as 2-view examinations are inadequate for detecting phalangeal fractures 4. An internally rotated oblique projection in addition to the standard externally rotated oblique increases diagnostic yield 4.
Mandatory follow-up radiographs must be obtained at 3 weeks post-injury to detect any delayed displacement that would necessitate surgical intervention 1, 2. Additional imaging should be performed at the time of immobilization removal (3-4 weeks) to confirm adequate healing 1, 5.
Absolute Indications for Surgical Conversion
You must convert to surgical fixation if any of the following develop: 1
- Displacement exceeds 3mm 1, 5, 2
- Any loss of joint congruity 1
- Intra-articular step-off of any significance 1
- Interfragmentary gap >3mm 4
- Palmar displacement of the distal fragment 4
- Involvement of more than one-third of the articular surface 4
These thresholds are critical because operative fixation resulting in <2mm of residual articular surface step-off is necessary to avoid long-term complications such as osteoarthritis 4.
Expected Complications and Pitfalls
Immobilization-related complications occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 1, 2. The most critical pitfall is failure to obtain 3-week follow-up radiographs, which can miss delayed displacement requiring surgical intervention 1, 2.
Joint stiffness is a major concern without proper early motion exercises 2, 6. Finger motion does not adversely affect adequately stabilized fractures in terms of reduction or healing, making early active motion safe and beneficial 5.
Why This Specific Fracture Pattern Matters
Volar base fractures of the middle phalanx involve the insertion site of the volar plate and can be associated with dorsal PIP joint instability 6. The "minimally displaced" designation is crucial—if the fracture involves a large fragment or shows any of the surgical thresholds mentioned above, the treatment paradigm shifts entirely to operative management 4, 1.
Do not confuse this with flexor digitorum profundus avulsion fractures (which occur at the volar base of the distal phalanx and usually require surgery) 6. The middle phalanx volar base fracture you're treating has a much better prognosis with conservative management when truly minimally displaced.