Nonoperative treatment

Undisplaced or minimally displaced diaphyseal and stable extraarticular fractures can be treated nonoperatively with splinting.

Most of these fractures produce an extension deformity and minimal shortening. Any malrotation and more than 2 mm shortening cannot be accepted, and operative treatment is recommended.

Irreducible rotational malalignment is an indication for operative treatment.

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

• Neutral wrist position or up to 15° extension
• Metacarpophalangeal (MCP) joint in 90° flexion
• Proximal interphalangeal (PIP) joint in extension

The reason for splinting the MCP joint in flexion is to maintain its collateral ligament at maximal length, avoiding scar contraction.

PIP joint extension in this position also maintains the length of the volar plate.

Both splints are easy to apply and there is no need for hand therapy.

A potential disadvantage of the palmar splint is the complete immobilization of uninjured fingers and joints. The MCP joint may not be in the optimal 90° flexion, which may lead to loss of motion.

The dorsal splint allows immediate active mobilization (flexion) of the finger joints.

Phalanx–Proximal Fractures–Extension Block Splint (Burke Halter)

Protect the skin of the arm and hand with padding/cotton sleeve to avoid pressure sores, especially on the distal ulna and styloid process of the radius.

In compliant patients, only the affected and the directly neighboring fingers may be included in the splint.

Create a splint of at least 6 slabs of cast bandage. It should cover the dorsal or palmar half of the forearm, wrist, and hand.

The wrist should be in neutral or up to 15° extension.

The splint is held in place with an elastic bandage. The bandage should not be overtightened at the level of the wrist joint to avoid excessive swelling of the hand.

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

In a dorsal splint, buddy strap the injured finger to an adjacent finger.

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.

X-ray checks of fracture position should be performed immediately after the splint has been applied.

Follow-up x-rays with the splint should be taken after 1 week and after 2 weeks if there is doubt about maintenance of reduction.

Splinting is continued until about 4 weeks after the injury. At that time, an x-ray without the splint is taken to confirm healing, and range of motion should be pain-free.

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

If, after 8 weeks, x-rays confirm healing, full manual loading can be permitted.