Nonoperative treatment

Undisplaced stable fractures of the metaphysis and diaphysis can be treated nonoperatively with controlled movement by buddy strapping to a neighboring finger. Some stable partial articular fractures may be treated in the same way.

The strapping should leave the joints free for mobilization.

Direct skin contact with adjacent fingers should be prevented by placing gauze pads between them.

Collateral ligament avulsion may be associated with a lateral dislocation of the PIP joint.

This can be reduced by traction with gentle laterally applied pressure on the middle phalanx to reduce the joint. This keeps the palmar structures in tension and reduced the risk of soft-tissue interposition.

Confirm reduction with an image intensifier and check the joint stability by varus/valgus stress test. This should show congruent movement compared with the adjacent joints.

If congruent reduction can not be achieved, often due to interposed soft tissue, an open reduction is necessary.

In this case, consider surgical treatment of the fracture.

The aftercare can be divided into four phases of healing:

• Inflammatory phase (week 1–3)
• Early repair phase (week 4–6)
• Late repair and early tissue remodeling phase (week 7–12)
• Remodeling and reintegration phase (week 13 onwards)

Full details on each phase can be found here.

If there is swelling, the hand is supported with a dorsal splint for a week. This should allow for movement of the unaffected fingers and help with pain and edema control. The arm should be actively elevated to help reduce the swelling.

The hand should be immobilized in an intrinsic plus (Edinburgh) position:

• Neutral wrist position or up to 15° extension
• MCP joint in 90° flexion
• PIP joint in extension

The MCP joint is splinted in flexion to maintain its collateral ligaments at maximal length to avoid contractures.

The PIP joint is splinted in extension to maintain the length of the volar plate.

After swelling has subsided, the finger is protected with buddy strapping to neutralize lateral forces on the finger.

Follow-up x-rays should be taken after 1 week and, if necessary, after 2 weeks. A final x-ray can be taken at the expected fracture consolidation.

In the middle phalanx, the fracture line can be visible in the x-ray for up to 6 months. Clinical evaluation (level of pain) is the most important indicator of fracture healing and consolidation.

Buddy strapping is continued until about 4 weeks after the injury. At that time, an x-ray may be taken to confirm healing.

Splinting can then usually be discontinued, and active mobilization is initiated. Functional exercises are recommended.

In the absence of pain during functional activities, full manual loading can be permitted. In case of doubt, an x-ray to confirm healing and consolidation, which would be expected by 8 weeks, should be taken.