Nonsurgical Treatment

There are so many ways to treat phalangeal fractures that the choice of approach depends on the experience, expertise, and personal preference of the physician. No single method of treatment can be applied to all fractures of the phalanx, and a surgeon must be comfortable with multiple techniques. Fracture healing takes the same amount of time no matter which method is chosen, if treatment is performed correctly.

Many fractures of the phalanges can be treated by closed reduction and cast immobilization. If the fracture pattern is stable (transverse), it can be treated nonsur-gically. Fracture patterns that are inherently unstable (spiral oblique) will fall out of alignment and will usually require surgical stabilization. Soft tissue conditions with any neurovascular compromise or swelling may prevent nonoperative treatment. The position for immobilization is the intrinsic-plus position, with the MP joint in at least 70 degrees, if not 90 degrees, of flexion and the PIP and distal interpha-langeal (DIP) joints in extension.

A proximal phalanx dorsal blocking cast with an adjacent finger held in the cast can be applied when the hand is in the intrinsic-plus position, contracture is avoided, and the intrinsics are maintained in a relaxed position. This position also effectively immobilizes stable fractures of the proximal phalanx (Fig. 39—2).

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