Treatment for Minimally Displaced Transverse Fracture of Small Finger Distal Phalanx
A minimally displaced transverse fracture of the distal phalanx of the small finger should be treated with a removable splint that immobilizes only the DIP joint for 3-4 weeks while allowing PIP joint motion, combined with active range-of-motion exercises of non-immobilized joints. 1
Initial Radiographic Assessment
- Obtain standard 3-view radiographs (PA, lateral, and oblique views) to confirm the fracture pattern and degree of displacement 2, 1
- Add an internally rotated oblique projection in addition to the standard externally rotated oblique to increase diagnostic yield 2
- Consider CT without IV contrast if radiographs are equivocal or if you need better characterization of fracture displacement 2
Conservative Management Protocol
For minimally displaced transverse fractures (displacement <3mm, no articular step-off >2mm), conservative treatment is appropriate:
- Apply a removable splint that immobilizes only the DIP joint while keeping the PIP and MCP joints free to move 2, 1
- Duration of immobilization should be 3-4 weeks 1
- Initiate active finger motion exercises immediately for all non-immobilized joints (PIP and MCP) to prevent stiffness 2, 1
Critical Pitfall: Rule Out Flexor Tendon Avulsion
Be vigilant for associated flexor digitorum profundus (FDP) tendon avulsion, which can be missed with nondisplaced transverse fractures of the distal phalanx 3:
- Examine for inability to actively flex the DIP joint
- Palpate for tenderness or mass in the palm (retracted tendon)
- If FDP avulsion is present, this requires surgical repair and changes management entirely 4, 3
Surgical Indications (When to Refer)
Refer for surgical fixation if any of the following are present:
- Displacement >3mm 2
- Articular step-off >2mm (if intra-articular extension exists) 2
- Interfragmentary gap >3mm 2
- Joint instability or incongruity 2
- Fractures involving more than one-third of the articular surface 2
Follow-up Protocol
- Obtain radiographs at 3 weeks post-immobilization to assess healing 2, 1
- Repeat radiographs at the time of splint removal (typically 3-4 weeks) to confirm adequate healing 2, 1
- Image earlier only if clinically indicated (new trauma, severe pain, loss of motion, or neurovascular symptoms)
Expected Complications and Prevention
- Joint stiffness is the most functionally disabling complication and occurs when joints are unnecessarily immobilized—this is why only the DIP joint should be splinted 2, 1
- Immobilization-related adverse events (skin irritation, muscle atrophy) occur in approximately 14.7% of cases 2, 1
- Post-traumatic arthritis can develop if intra-articular fractures are inadequately treated 1
Key Clinical Pearls
- Most distal phalanx fractures are sustained in crushing injuries and require more attention to soft tissue care than to the fracture itself 4
- Never immobilize the PIP or MCP joints for an isolated distal phalanx fracture—this dramatically increases stiffness risk 2
- Transverse fractures at the base of the distal phalanx (Seymour's fracture) have higher infection risk and may require K-wire fixation if displaced 5