Treatment of Closed, Nondisplaced Distal Phalanx Fractures
For closed, nondisplaced fractures of the distal phalanx, conservative management with protective splinting is the treatment of choice, as these fractures rarely require specific treatment for the fracture itself and heal reliably without surgery. 1
Initial Management Approach
Immobilize the affected digit with protective splinting while ensuring full range of motion of adjacent uninjured fingers. 1 The primary focus should be on managing the surrounding soft tissue injury, as distal phalanx fractures typically result from crushing mechanisms that cause more soft tissue damage than bony instability 1.
Key Treatment Principles
- Non-operative management is preferred for stable, extra-articular distal phalanx fractures, which includes most nondisplaced fractures 2
- The splint should never obstruct finger motion of adjacent digits, as finger stiffness is one of the most functionally disabling complications 3
- Initiate active motion exercises of uninjured fingers immediately to prevent stiffness 3
Immobilization Protocol
Duration and Follow-up:
- Maintain protective splinting for approximately 3 weeks 3
- Obtain radiographic follow-up at 3 weeks to confirm maintenance of alignment and adequate healing 3
- Repeat imaging at the time of immobilization removal 3
Critical Caveats and Exceptions
Watch for these specific patterns that require surgical intervention:
- Displaced dorsal articular fractures (mallet fractures) can be treated nonoperatively, though this remains somewhat controversial 1
- Displaced palmar articular fractures associated with flexor digitorum profundus tendon avulsion require surgical replacement 1
- Any fracture showing displacement >3mm on follow-up imaging warrants consideration for surgical fixation 3, 4
Monitoring for Complications
Common complications to monitor include:
- Skin irritation and muscle atrophy (occurs in approximately 14.7% of immobilization cases) 3
- Loss of reduction during healing—even initially nondisplaced fractures can displace 3
- Malrotation, which would necessitate operative treatment 5
Why This Approach Works
The evidence strongly supports conservative management because distal phalanx fractures sustained in crushing injuries heal reliably without specific fracture treatment 1. The soft tissue envelope is the primary concern, not the bone itself 1. Most hand fractures, including distal phalanx fractures, demonstrate excellent outcomes with non-operative treatment that cannot be reliably improved with surgery 6.
Do not prolong immobilization beyond what is necessary for fracture stability, as extended immobilization increases stiffness risk 3. Once the fracture is stable (typically 3 weeks), begin gentle range of motion exercises of the affected digit.