From the Guidelines
For a displaced avulsion fracture at the volar aspect of the middle phalanx base of the fifth digit without dislocation, I recommend prompt orthopedic consultation for potential surgical fixation, as this injury likely represents a volar plate avulsion which often requires surgical intervention when significantly displaced, as suggested by the principles outlined in 1 and 1. This approach prioritizes minimizing morbidity, mortality, and optimizing quality of life by addressing the fracture properly to prevent potential complications such as chronic pain, instability of the PIP joint, or flexion contractures that could significantly impact hand function. While awaiting definitive treatment, the finger should be immobilized in a dorsal splint with the PIP joint in slight flexion (approximately 20-30 degrees) to reduce tension on the volar plate, as per general principles of fracture management. Pain management with acetaminophen 650mg every 6 hours and/or ibuprofen 400-600mg every 6 hours as needed, unless contraindicated, should be provided, alongside elevation of the hand above heart level and application of ice for 15-20 minutes every 2-3 hours to reduce swelling. If surgery is not indicated, conservative management typically involves 3-4 weeks of splinting followed by protected range of motion exercises, emphasizing the importance of close follow-up within 7-10 days to ensure proper healing and to adjust the treatment plan as needed, aligning with first aid principles for fractures outlined in 1. Key considerations include:
- Prompt orthopedic consultation for potential surgical fixation
- Immobilization in a dorsal splint
- Pain management
- Elevation and ice application to reduce swelling
- Close follow-up for adjustment of the treatment plan These steps are crucial in managing the displaced avulsion fracture effectively, prioritizing the patient's morbidity, mortality, and quality of life outcomes.
From the Research
Assessment and Treatment Options
The patient presents with a displaced avulsion fracture on the volar aspect of the base of the middle phalanx of the fifth digit, without dislocation. Considering the severity and location of the fracture, the following treatment options can be explored:
- Conservative management may include casting or splinting with immobilization, as suggested by 2. However, this approach may be more suitable for less severe cases.
- Surgical intervention is typically indicated for more severe cases or when nonoperative treatments fail, as noted in 2. The goal of surgery is to achieve anatomical alignment and stability, which can be crucial for preventing long-term complications such as deformity, nonunion, or malunion.
- Open reduction and internal fixation (ORIF) is a surgical technique that has been used successfully in similar cases, as reported in 3. This approach can provide stable fixation and allow for early mobilization.
- Other surgical techniques, such as hook plate fixation, have also shown promising results in treating avulsion fractures around joints, as demonstrated in 4. This method offers reliable fixation, early rehabilitation, and high recovery rates of joint function.
Potential Complications and Considerations
When considering treatment options, it is essential to be aware of potential complications associated with each approach:
- Casting and splinting can lead to stiffness, pressure sores, and compartment syndrome, especially when applied by less experienced practitioners, as highlighted in 5.
- Surgical interventions, such as ORIF or hook plate fixation, carry risks of vascular or nerve injuries, infection, and traumatic arthritis, although these complications can be minimized with proper technique and postoperative care.
- Patient demographics, preferences, and surgeon experience can also influence the choice of treatment, as noted in 2.