What is the management for a patient presenting with a displaced avulsion fracture on the volar aspect of the base of the middle phalanx of the fifth digit (Emergency Department, ED)?

From the Guidelines

For a displaced avulsion fracture of the volar aspect of the base of the middle phalanx of the fifth digit, immediate orthopedic consultation is recommended to assess the need for surgical fixation or closed reduction. This injury likely represents a volar plate avulsion, which requires proper reduction and immobilization to prevent long-term morbidity and mortality related to joint stiffness and dysfunction. The emergency physician should obtain appropriate radiographs (AP, lateral, and oblique views) to assess fracture displacement and any joint involvement, as recommended by the American College of Radiology 1. While awaiting orthopedic evaluation, the digit should be immobilized in a dorsal aluminum splint with the PIP joint in approximately 20-30 degrees of flexion to reduce tension on the volar plate. Pain management should include acetaminophen 650mg every 6 hours and/or ibuprofen 600mg every 8 hours as needed, avoiding opioids if possible. Ice application for 15-20 minutes every 2-3 hours and elevation above heart level will help reduce swelling. Most of these fractures require closed reduction under digital block anesthesia (using 1-2ml of 1% lidocaine without epinephrine) followed by splinting, though significantly displaced fragments may require surgical fixation, as indicated by the presence of palmar displacement of the distal phalanx or an interfragmentary gap of >3 mm 1. The typical immobilization period is 3-4 weeks, with follow-up in 7-10 days to assess healing and potentially begin protected range of motion exercises to prevent stiffness. Key considerations in management include:

• Obtaining appropriate radiographs to assess fracture displacement and joint involvement
• Immobilizing the digit in a dorsal aluminum splint to reduce tension on the volar plate
• Providing pain management with acetaminophen and/or ibuprofen
• Applying ice and elevating the affected limb to reduce swelling
• Considering closed reduction under digital block anesthesia or surgical fixation for significantly displaced fragments. This approach balances the need to protect the healing fracture while minimizing the risk of permanent joint stiffness that can occur with prolonged immobilization, ultimately prioritizing the patient's quality of life and reducing morbidity and mortality related to the injury.

From the Research

Treatment Options for Displaced Avulsion Fracture

• The patient presents with a displaced avulsion fracture on the volar aspect of the base of the middle phalanx of the fifth digit.
• According to the study by 2, open reduction and internal fixation is a suitable treatment option for large volar plate avulsion fractures at the base of the middle phalanx with significant displacement.
• The study reports that all patients who underwent open reduction and internal fixation achieved fracture healing in anatomic alignment without articular incongruity or instability.

Comparison with Other Fracture Treatments

• Other studies have investigated treatment options for different types of fractures, including:
  • Displaced scapular fractures: open reduction and internal fixation is recommended for displaced scapular fractures, with good results reported in 64% of patients 3.
  • Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation, and open reduction with internal fixation found that external fixation yielded the best results, with 80% of patients achieving good or excellent outcomes 4.
  • Posterior cruciate ligament tibial insertion avulsion: open reduction and internal fixation using plate and screws through a direct posterior approach has been shown to be an effective treatment option, with excellent results reported in 87% of patients 5.

Considerations for Treatment

• The choice of treatment for a displaced avulsion fracture on the volar aspect of the base of the middle phalanx of the fifth digit should be based on the individual patient's condition and the severity of the fracture.
• Open reduction and internal fixation may be a suitable treatment option, as it has been shown to be effective in achieving fracture healing in anatomic alignment without articular incongruity or instability 2.