Should a 12-year-old healthy boy with a volar fracture of the middle phalanx of the fourth finger that is radiographically healing after four weeks of splinting and is pain-free continue splinting for another two weeks or begin mobilization?

Management of Healing Middle Phalanx Fracture in a 12-Year-Old After 4 Weeks

Begin mobilization now—this child should discontinue splinting and start active motion exercises immediately. 1, 2

Rationale for Early Mobilization

For pediatric middle phalanx fractures that are radiographically healing and pain-free at 3-4 weeks, continued immobilization provides no benefit and increases the risk of finger stiffness. 1, 2

• A 2024 randomized controlled trial (Level 1 evidence) in children with proximal phalangeal fractures demonstrated that those who were clinically healed at 3 weeks and discontinued splinting had equivalent outcomes to those splinted for the standard 5 weeks. 2
• The study specifically showed that therapist assessment of clinical healing (absence of pain, radiographic healing) is an appropriate indicator to cease immobilization. 2
• Children presenting as clinically healed at 3 weeks post-injury do not benefit from additional immobilization. 2

Clinical Healing Criteria Met

Your patient meets all criteria for mobilization:

• Radiographic evidence of healing (callus formation visible on repeat X-ray) 1
• Pain-free status (no tenderness with palpation or movement) 3, 2
• Four weeks of immobilization completed (exceeds the 3-week threshold for clinical healing assessment) 1, 2

Mobilization Protocol

Initiate active finger motion exercises immediately for all joints of the affected finger. 1

• Active motion does not adversely affect adequately stabilized fractures and is extremely cost-effective. 1
• Begin with gentle active range of motion exercises for the PIP and DIP joints multiple times daily. 1
• Buddy taping to the adjacent finger during activities may provide comfort and protection during the transition phase. 3, 4

Risks of Continued Immobilization

Over-immobilization beyond clinical healing leads to unnecessary finger stiffness that can be very difficult to treat. 1

• Hand stiffness after prolonged immobilization may require multiple therapy visits and possibly surgical intervention. 1
• Delayed motion increases the risk of permanent stiffness in pediatric patients. 1
• The critical window for preventing stiffness is to begin motion as soon as fracture stability allows. 1, 5

Follow-Up Imaging

Obtain radiographic follow-up at approximately 6 weeks (2 weeks from now) to confirm continued healing. 1

• This timing aligns with standard practice for middle phalanx fractures. 1
• No difference exists in outcomes based on frequency of radiographic evaluation for healing fractures. 6
• Clinical assessment (pain, function, deformity) is more important than radiographic appearance once initial healing is documented. 2

Common Pitfall to Avoid

The most common error is rigid splinting when mobilization is indicated, leading to preventable stiffness. 1

• Traditional protocols recommending 5-6 weeks of immobilization for all middle phalanx fractures are outdated for pediatric patients who demonstrate clinical healing earlier. 3, 2
• Children heal faster than adults due to robust periosteal response and remodeling capacity. 7, 4