Management of Undisplaced Volar Proximal Middle Phalanx Fracture at PIP Joint
For an undisplaced volar proximal middle phalanx fracture at the PIP joint following hyperextension injury, buddy taping to an adjacent finger for 2-3 weeks is the appropriate initial treatment, with immediate return for worsening pain, as these injuries can progress to instability requiring surgical intervention. 1, 2
Initial Assessment and Imaging
- Obtain standard 3-view radiographs (posteroanterior, lateral, and oblique) immediately to confirm the fracture is truly undisplaced and to assess the percentage of articular surface involvement 3, 1
- The lateral view is critical to evaluate for volar subluxation of the middle phalanx, which would change management entirely 1
- Document the exact percentage of articular surface involved by the fracture fragment - fragments involving ≥30% of the articular surface with any displacement or rotation require surgical referral 4, 5
Conservative Management Protocol
Buddy taping is superior to aluminum splinting for undisplaced PIP hyperextension injuries, allowing earlier recovery of motion, resolution of edema, and pain relief 2
- Apply buddy taping with padding between the injured finger and adjacent finger for 2-3 weeks 1, 2
- Begin active range of motion exercises of the MCP joint immediately while maintaining buddy taping to prevent stiffness 6
- Apply ice-water mixture for 10-20 minutes with a thin towel barrier during the first 48-72 hours to control swelling 6
Critical Red Flags Requiring Urgent Re-evaluation
Worsening pain after 2 weeks despite conservative treatment is a red flag demanding advanced imaging, as initial radiographs can miss injuries requiring surgery 1
- Volar subluxation on lateral radiographs is an absolute surgical indication, even with small fracture fragments 6
- Loss of volar stability with hyperextension stress testing indicates volar plate disruption requiring surgical consideration 4
- Fracture fragments that are rotated 90 degrees (even if initially appearing "undisplaced") require open reduction and internal fixation 4
Advanced Imaging Indications
If pain persists or worsens at 10-14 days, obtain MRI without IV contrast (94% sensitivity, 98% specificity for occult injuries) to evaluate for 1:
- Volar plate tears not involving bone that can lead to chronic hyperextension deformity 7, 8
- Collateral ligament injuries contributing to instability 7
- Occult fracture extension or fragment rotation not visible on plain films 1
Alternatively, repeat plain radiographs at 10-14 days may reveal early callus formation from healing, confirming the diagnosis 1
Surgical Referral Criteria
Immediate hand surgery referral is mandatory for 6, 4, 5:
- Fracture fragments involving ≥30% of the articular surface with any displacement or rotation
- Volar subluxation of the middle phalanx on lateral radiographs
- Interfragmentary gap >3mm
- Loss of volar stability on clinical examination
- Open injuries
Common Pitfalls to Avoid
- Do not rely on 2-view radiographs alone - they are inadequate for detecting PIP joint fractures and can miss critical pathology 1
- Do not dismiss these injuries as "simple sprains" - untreated PIP fracture-dislocations have poor outcomes and limited chance of regaining normal motion if treatment is delayed 5
- Do not immobilize in extension - if any splinting is used, position should be in 15° flexion to prevent hyperextension stress 2
- Avoid heat application initially - use ice/cold therapy instead for pain and swelling control 6
Expected Outcomes
With appropriate conservative management of truly undisplaced fractures, patients typically achieve 92° average PIP flexion (range 75-98°) with minimal flexion contracture (average 9°, range 0-20°) 8. Children have better outcomes than adults with these injuries 2.