Proximal Phalanx Fracture: Evaluation and Management
Initial Evaluation
Begin with standard three-view radiography (posteroanterior, lateral, and oblique) as the definitive initial imaging for any suspected proximal phalanx fracture. 1, 2
Clinical Assessment
- Document the mechanism of injury (direct blow, axial loading during ball sports, or crush injury) as this predicts fracture pattern 3, 4
- Assess for malrotation by having the patient make a fist—all fingernails should point toward the scaphoid tubercle 3
- Measure angulation on radiographs: >10 degrees requires reduction or surgical intervention 3
- Evaluate for articular involvement, displacement >2mm, or comminution on all three radiographic views 1, 2
Key Radiographic Findings
- Operative indications include: >2mm articular step-off, >10 degrees angulation, malrotation, or significant displacement 2, 3
- Unicondylar fractures (especially distal condyle) commonly occur from axial splitting forces during ball sports 4
- Base fractures of the fifth digit are the most amenable to conservative management 5
Treatment Algorithm
Stable, Non-Displaced Fractures (<10 degrees angulation)
- Buddy taping to adjacent digit with immediate mobilization is the preferred treatment for stable base fractures, particularly of the fifth digit 5
- Splint immobilization for 4-6 weeks for stable shaft fractures 3, 6
- Begin active range of motion exercises of uninvolved joints immediately to prevent stiffness 7
Unstable or Displaced Fractures
For unstable proximal phalanx fractures requiring fixation, multiple Kirschner wire fixation provides the most predictable outcomes with superior final joint motion compared to single-wire fixation. 4, 8
Specific Fracture Patterns:
- Transverse and short oblique shaft fractures: Percutaneous 1.0mm intramedullary Kirschner wires following closed or open reduction 8, 6
- Spiral long oblique fractures: Lag screw fixation 8
- Unicondylar fractures: Early closed reduction with multiple Kirschner wire fixation (single-wire fixation has high displacement rates) 4, 8
- Bicondylar fractures: Plate fixation 8
- Comminuted fractures: Plate fixation 8
Post-Fixation Management
- Short immobilization periods (2-3 weeks) do not adversely affect final proximal interphalangeal joint motion 4
- Early mobilization after stable fixation optimizes functional outcomes 5, 6
- Buddy taping during rehabilitation phase prevents re-injury while allowing motion 5
Critical Pitfalls to Avoid
- Do not rely on two-view radiographs alone—three views are mandatory to detect fracture patterns and displacement 1, 2
- Single Kirschner wire fixation has high failure rates—use multiple wires or alternative fixation for displaced fractures 4
- Do not accept >10 degrees angulation or any malrotation—these require reduction or surgical referral 3
- Class IV unicondylar fractures with small palmar coronal fragments have the poorest outcomes—consider early surgical referral 4
- Prolonged immobilization without joint mobilization leads to permanent stiffness—begin adjacent joint motion immediately 7, 5
Expected Outcomes
- Stable fractures treated conservatively achieve full flexion in >95% of cases with buddy taping and immediate mobilization 5
- Unstable fractures treated with appropriate Kirschner wire fixation achieve excellent (TAM ≥220°) or good (TAM 180-220°) results in 84% of cases 6
- Non-union is rare (<5%) with appropriate treatment 5, 6
- Grip strength typically returns to baseline of contralateral hand 6